Based on the KSS Guide to Trainers for assessing OOHs competencies with additional material on expansion of the COGPED traffic light system based on the work of the Cheltenham Trainers Group.

COGPED Traffic Light System

Detailed Guide to Competency and Supervision Progression

Glossary of Abreviations 
GPST - GP Specialist Trainee
OOH - Out of Hours
CCT - Certificate of Completion of Training
RCGP - Royal College of General Practitioners
COGPED - Committee of General Practice Education Directors
COT - Consultation Observation Tool
CbD - Case-based Discussion
PDP - Personal Development Plan


Introduction 

The purpose of this document is to provide guidance on how to assess competence in out of hours clinical practice (OOH Competence) of GP Specialty Trainees (GPSTs).

This document should be read in conjunction with:

Background 

The assessment of OOH Competence is an essential element of the workplace based assessment component of the MRCGP examination. Educational Supervisors are therefore required to sign off their GPST as being competent in OOH as part of the final review. A GPST cannot therefore apply for their Certificate of Completion of Training (CCT) without this OOH Competence box being ticked. In ticking this box educational supervisors are confirming their trainee’s competency, not just that they have completed the minimum numbers of hours required.

Rationale 

This guide is intended to help with two potential problems:

  • Many Educational Supervisors do not directly supervise their GPSTs in OOH practice. Therefore it can be difficult to know what evidence can be used to assess the OOH Competence of their GPST.
  • To ensure good clinical governance OOH providers need some kind of assessment to know when a GPST is ready to move from closely supervised (Amber) shifts to remotely supervised (Green) shifts.

The Key Out of Hours Competencies 

The six generic competencies, embedded within the RCGP Curriculum Statement on ;Care of acutely ill people, are defined as the:

  • Ability to manage common medical, surgical and psychiatric emergencies in the out-of-hours setting.
  • Understanding of the organisational aspects of NHS out of hours care.
  • Ability to make appropriate referrals to hospitals and other professionals in the out-of-hours setting.
  • Demonstration of communication skills required for out-of-hours care.
  • Individual personal time and stress management.
  • Maintenance of personal security and awareness and management of the security risks to others.

Palliative care 

Palliative care can form a significant part of OOH work. GPSTs should be familiar with the learning outcomes of section 12 of the RCGP Curriculum: Care of People with Cancer and Palliative Care - this is to be revised in line with the new curriculum.

Assessment of OOH Competence 

GPSTs need to demonstrate competency in the provision of OOH care. The overall responsibility for assessment of competency is with the Educational Supervisor but GPSTs have a duty to keep the record of their experience, reflection and feedback in the competency domains. This record should be kept within the e-Portfolio.

The assessment of OOH Competence should be triangulated from several sources of evidence. This may include:

  • An initial trainee self-assessment against GP Curriculum learning outcomes (Trainee Workbook Appendix A)
  • An assessment of knowledge of common OOH and important emergency scenarios (Appendix A)
  • A declaration by the OOH supervisor (Trainee Workbook Appendix F)
  • An audio-COT assessment
  • An OOH CbD assessment

An Educational Supervisor may also use additional evidence from in-hours practice that may demonstrate competence of learning outcomes from the RCGP Curriculum Statement on ‘Care of acutely ill people’.

Trainee self-assessment 

GPSTs should be encouraged to complete the OOH Self-Assessment Tool (Trainee Workbook Appendix A) prior to starting their OOH sessions. This will not only familiarise them with the learning outcomes from the GP Curriculum, but also allow them to set specific learning objectives which they may wish to record on their PDP.

The Self-Assessment Tool may be re-visited at intervals throughout the training programme and prior to the final review to assess progress.

Assessment of knowledge of common OOH and important emergency scenarios 

GPSTs need to be able to manage both common conditions and recognise important medical emergencies with which they may be faced whilst doing OOH clinical practice. This can be assessed using the OOH Care Short Answer Questionnaire (Appendix A).

Declaration by OOH Supervisor 

Before the GPST can progress from doing closely supervised (Amber) shifts to remotely supervised (Green) within the OOH organisation it is good practice for the OOH Supervisor who has been supervising the GPST to sign a declaration that they have no concerns with the GPST’s performance. This should then be shared with both the OOH organisation and the GPST’s Educational Supervisor. Such a declaration will be based on observed practice whilst under close supervision (Trainee Workbook Appendix F). See later for further guidance on the COGPED traffic light system for levels of clinical supervision in OOH.

Audio-COT Assessment 

An assessment of the GPST’s performance can be made using an audio recording of a telephone consultation that the GPST has performed whilst doing an OOH shift. This should be recorded in the GPST’s e-Portfolio in the same way as one would record a video-COT, using the same assessment framework. This can be completed by a clinical supervisor if they are competent to do so (many trainers provide clinical supervision for trainees other than their own).

The OOH provider would need to provide the audio recording for the purpose of this assessment. (There is variation between OOHs providers in access to these recordings) Alternatively the assessment could be done “live” using a training headset or in an observed OOH surgery if the opportunity arises.

OOH CBD Assessment 

A CBD assessment can be done using cases from the GPST’s OOH practice.  The OOH provider would need to provide a print out of the OOH clinical records for the purpose of this assessment. The Educational Supervisor may wish to focus the discussion around relevant learning outcomes from the RCGP Curriculum Statement on ‘Care of acutely ill people’. The assessment would be recorded in the GPST’s e-Portfolio. Again can be completed by a competent clinical supervisor.

Severn Guidance 

The Deanery requires trainees to work a minimum of 6 hours on average per month pro-rata FTE (full time equivalent) while they are in a GP post, which includes GP posts undertaken in ST1 and 2. GPSTs are required to undertake a minimum of 72hours OOH experience in ST3 to satisfy e-portfolio requirements. However trainees may require more than 72hours experience in ST3 to achieve the competencies associated with OOH work, especially if they work in areas with low activity levels.

Trainees are required to complete at least 36hrs OOHs in first 6 months of ST3 to ensure that their competency progression is satisfactory and to allow sufficient time for additional training if it is not. Trainees are required to do at least 18 hours at green level of supervision before the end of ST3. Trainees should include the number of hours worked and the supervision level (red, amber, green) in the heading of each OOH log in their e-portfolio to allow their trainer to see how many hours, and at which level, have been completed without having to open each individual log entry.

Administrative issues-Honorary Contracts, Induction, Booking Shifts 

Trainees should register with the OOH provider that covers their practice area prior to starting their GP placement and are encouraged to book shifts early to try spread their shifts evenly, and avoid trainees trying to squeeze shifts into a few months. All OOH providers should provide an induction to new trainees starting shifts with their service. All trainees should sign an honorary contract and have their own login for the clinical system. This will be looked at as part of the QA visiting process currently being rolled out.

Additional Approved OOHs experiences 

In addition to experience with providers of GP OOH services trainees may gain experience with other OOH services as follows:

  • Walk in Centre – up to 18 hrs with an approved clinical supervisor
  • Ambulance-1 shift with para-medic crew
  • NHS Direct – 1 shift observing
  • Mental Health Crisis Team – 1 shift
  • Telephone Triage Course – 1 session
  • As provision and services continue to evolve trainees can apply to their local APD/OOH Deanery Lead for prospective approval for specific OOH opportunities that might arise

It is advised that additional OOHs experiences should normally be undertaken during ST1/2 GP posts for a maximum of 12 hours. The focus in ST3 being on the acquisition of the required competencies through working in an OOHs provider organisation.

Key Points 

  • Minimum 6 hours OOH work on average per month when in a GP posts
  • Must complete at least 36 hours in first 6 months of ST3
  • At least 18 hours at Green prior to completing training
  • Trainees should receive an induction prior to commencing OOH
  • Trainees are required to fill out a ‘ Record of OOH session' page for each session, the OOH supervisor will also comment on this form at the end of each shift. (Appendix D)
  • All shifts should ALSO be recorded within the LEARNING LOG section of the ePortfolio, under OOH sessions with the number of hours and supervision level to be recorded in log entry heading and the Record of OOH session sheet scanned in as an attachment to the log entry. The learning log entry can refer to the Record of OOH session to avoid duplication but should contain a reflective element.
  • These OOH sessions should be shared with you, their trainer, to enable you to assess the trainee’s progress towards acquisition of the OOH competencies and the minimum of 72 hours of OOH work throughout the year.
  • Each entry for OOH should normally be linked to section 7 of the curriculum, Care of acutely ill people, and of course anywhere else that is appropriate

 

Appendix A 

OOH CARE SHORT ANSWER QUESTIONNAIRE

This short answer questionnaire has been adapted from the Canbury Emergencies in General Practice Questionnaire. It can be used to assess knowledge of both common conditions and medical emergencies that may present in OOH clinical practice.

The questionnaire can be conducted either as an oral or written assessment.

For each scenario the following questions should be asked:

  • What is your diagnosis
  • What is your differential diagnosis
  • How would you manage this scenario in an OOH situation

Cardiovascular system

  • 78yr man SOB at night in winter
  • Middle-aged man, central chest pain and refers to left arm
  • 27yr woman with sudden onset of pleuritic pain and haemoptysis
  • 58yr sudden onset painful, cold pale leg
  • Faintness, abdominal and back pain in 81yr man
  • 41 yr woman with sudden onset of occipital headache
  • 21 yr woman unilaterally painful swollen lower leg
  • 33yr man sudden onset unilateral headache
  • 61yr female increasingly severe chest pain and shortness of breath over a few days
  • 66yr female palpitations and breathless

Gastrointestinal

  • 28 yr old man with haematemesis after stag night
  • Worsening abdominal pain in a 46yr old man with history of dyspepsia
  • Vomiting in a 6 week baby boy
  • Blood stained diarrhoea in 70 year old
  • Severe bleeding PR in 51yr old woman
  • Abdominal pain after minor RTA in 33yr old
  • 44 year old woman with right upper quadrant abdominal pain and fever
  • 14 yr old boy with severe abdominal pain and vomiting
  • Diarrhoea and vomiting 26yr old woman for 48hrs
  • Diarrhoea and vomiting 6yr old boy with fever

Orthopaedics

  • 18 month old refusing to walk
  • 14 year old with painful hip
  • 75 year old lady unable to move one leg
  • 49 yr man with back pain and unable to pass urine
  • 3yr old girl with painful arm and not moving her elbow
  • 22yr old footballer with tender swollen ankle

Ophthalmology

  • 30 yr old man with sore eye after changing car exhaust
  • Severe painful eye with vomiting in 50yr old woman

Respiratory

  • 3yr old feels hot, looks ill, breathing sounds chesty, quiet
  • Chest pain in 33yr man, sudden onset of breathlessness
  • Hot, sweaty child, sore throat and dribbling, unable to swallow
  • 5yr old boy with fever and earache
  • Acute shortness of breath in 78yr woman known to have COPD
  • 4yr old girl has just woken up struggling to breathe and barking cough
  • Cough and chest pain with haemoptysis

Obstetrics and Gynaecology

  • 28 week pregnancy with slight pv bleed
  • 36 week pregnant with headache & oedema
  • 15 year old with heavy and painful blood loss
  • 28 week pregnant with chest pain
  • IUD fitted today, now has abdominal pains
  • 32yrs iliac fossa pain, period late
  • 17yr brown PV discharge and pelvic pain
  • 21yr foul smelling PV discharge, feeling faint & fever

Neurological

  • 39yr woman sudden onset of severe occipital headache
  • Unexpectedly confused 80yr lady, more than a week after a fall
  • A pyrexial twitching child
  • Pyrexial child with mottled rash
  • 59 year old woman 1 hr history of weak right arm

Urological

  • 39yr man with agonising loin pain
  • 28 yr cyclist with pain in left testicle for past hour
  • Elderly man has not passed urine for 12 hours
  • Child with vomiting and rigors
  • 18 yr man swollen penis for 6 hours

Psychological

  • Agitated, excited young man talking nonsense
  • Withdrawn morose nurse with access to insulin
  • 34yr old man who split up with girlfriend, has been drinking & now threatening suicide
  • 42yr schizophrenic man increasingly agitated & aggressive

Miscellaneous

  • Expected death of a 90 yr old woman in a nursing home
  • Unexpected death of 67 yr old man at home, history of angina