1. Why have these changes been brought about?

OOH is changing. With GP surgeries offering evening & weekend appointments, and new in-hours urgent care providers developing, the lines between “in” and “out” of hours practice are blurring. In addition, the OOH workforce is diversifying. Our OOH training needs to adapt to these changes. Trainees need exposure to these changes.

2. What are the key changes to OOH training?

• A move away from counting the number of hours worked OOH, to an approach that looks at the number of competencies trainees have reached whilst working in a variety of OOH locations
• Where general practitioners are not available on site, allowing the use of allied care practitioners to contribute towards trainee supervision as part of an effort to learn from and appreciate the skills held by these colleagues, considering their increased presence within OOH services with safeguards to ensure there is a qualified GP to whom issues can be escalated
• Allowing senior trainees the option of completing unsupervised (“solo”) OOHs shifts, moving away from these being a mandatory requirement, but ensuring the opportunity is there prior to CCT if the trainee feels it will add value to training.

3. Do I still need to do OOH training?

Absolutely. All trainees still have to complete OOH training. Trainees still need to use the OOH setting to sign off appropriate competencies and all trainees must have the opportunity to experience delivery of OOH primary care in settings away from their usual place of practice.

4. Why has the USSC guidance changed from ‘counting hours’ to competencies?

The guidance reflects an overall move towards individual training designed around individual trainees and their personal educational and training needs. It is recognized that trainees have different learning needs and can meet them in a variety of ways and at variable paces. Accordingly, it follows that simply counting hours may not correlate with the actual clinical experience and subsequent knowledge and competencies that are demonstrated. It is the intention that the new guidance will be more robust at ensuring all trainees are fully competent in UUSC by CCT.

5. How many hours of UUSC do ST3 trainees now need to complete during their training?

There is no longer a minimum required number of hours of urgent and unscheduled care work trainees have to complete prior to CCT. In rolling out this new guidance for trainees, the GP School considers that the nature of work GPs do in the urgent care setting has not fundamentally changed.

The emphasis in the new guidance is on achieving competence, and whilst there is clear national guidance that we cannot stipulate a minimum number of hours worked outside the practice setting, we do know that it used to take most trainees around 72 hours in ST3 to achieve competence in all aspects of UUSC. In all cases a sign off as "competent" will need to be justified by the evidence provided.

6. What if a trainee has demonstrated competence in UUSC but wants to continue to do more UUSC shifts to gain more experience and confidence?

GP training is varied and individual with underlying key competencies that must be demonstrated. This is to allow trainees to take advantage of a broad range of educational experiences to prepare them to work as generalists, but also to enable them to adapt their training to meet their individual learning needs, special interests and future career plans. If a trainee feels the need to develop their UUSC experience and confidence further this should be documented in their PDP and would be supported by the GP School. To do this they would be expected to be on track with demonstrating competency in all other areas of training in time for their scheduled CCT date.

7. Is there a maximum number of hours trainees can work in the UUSC setting?

There is no upper limit on the number of hours trainees can work in the UUSC setting so long as they adhere to the limits of safe working practice as detailed in the new Junior Doctors Contract.

8. Is there a minimum number of hours trainees can work in the UUSC setting?

There is no lower limit on the number of hours trainees must work in the UUSC setting as noted above. Full UUSC competencies must be demonstrated however and it would be considered difficult to achieve this without reasonable work in the UUSC setting.

We would ask that Educational Supervisors support a pragmatic variety of IUC experience which does not prevent a trainee gaining the required competence by restricting his or her opportunities: gaining the competence will certainly involve work outside of the surgery premises as well as within, and outside of normal working hours. Further explanation of this can be found here.

9. Time spent working in UUSC is taken out of the trainees clinical working week in the training practice and can be hard to accommodate on the practice’s clinical rota and can lead to the practice being short of appointments. Can you suggest how a practice can facilitate the trainee gaining enough experience while balancing the administrative and clinical needs of the practice?

The GP School expects educational supervisors, and their training practices, to support trainees learning in UUSC. It is however recognised that practices need to plan rotas, rooms and other logistics and therefore need to know when a trainee will be working. The GP School would encourage trainees to give a reasonable amount (to be agreed in each practice but usually of the order of 4-6 weeks) of notice for clinical time off in lieu (TOIL) due to urgent care shifts worked. If reasonable notice is given, we would expect practices to be able to accommodate this.

When the previous guidance was in place many practices scheduled six hours of time off in lieu per month into timetables to assist forward planning and to balance out time worked in UUSC outside the practice. A comparable system could be agreed between the trainee and practice if preferable.

10. Is the guidance different for less than full time (LTFT) trainees?

LTFT trainees need to demonstrate competence in all six UUSC care competencies by the end of ST3 as full time trainees do. It is up to the trainee to decide how they can achieve this. There is no need to consider ‘pro rata’ UUSC work given there is no specified minimum or maximum number of hours any trainee must complete.

11. I have already completed shifts in UUSC but will not be qualified before August 2019. Can I continue to work towards the old hours-based guidance, or do I have to move to competency-based guidance, and if so, do I have to start from scratch?

After the implementation of competency-based guidance on 7th August 2019 no formal hour’s audit will be performed. However, it is recognized that a flexible approach is needed for trainees bridging the two systems. Severn GP School would expect affected trainees and their ES to have a discussion around the time of transition about which competencies have been obtained so far and where the evidence for this is (with the recommendation that this is documented in the competency log). It will then be clear what further experience and training is required for the trainee to meet their competencies. It is not anticipated that this will be an onerous task and in fact is what will have been happening in the majority of ESR meetings historically within the time-based guidance.

12. Do ST1/2s need to do UUSC work?

The new guidance does not make a formal stipulation as to what should happen over each of the three years of training but expects all trainees to have achieved competence by the end of ST3. In order to achieve this we would suggest trainees start to familiarise themselves with the breadth of UUSC in their area during their GP placements in ST1 or 2. This could include observation of others (which will count towards weekly educational time - see below) or experience working in urgent care providers (which may count towards weekly clinical time - see below). We would expect trainees to arrange sufficient exposure such that they are ready to work with an UUSC provider in a patient facing capacity from the start of ST3 at the latest.

13. Do LEETs need to do UUSC work as part of their extension to training?

LEET trainees will have demonstrated full competence in UUSC ready for CCT prior to commencing their ST4 year. Though there is no longer a minimum requirement of UUSC work during this ST4 year the GP School would expect trainees to engage in a sufficient volume of work to ensure they maintain the competencies they have already demonstrated.

14. Can a trainee spend time with paramedics, the crisis team or other allied healthcare professionals as they used to in ST1/2?

The GP School considers time observing colleagues and teams who support GPs in offering UUSC a valuable element of training, particularly for trainees who feel they haven’t covered these areas in other aspects of their training. Observation, including sitting in with a GP and watching them consult, is considered educational and therefore counts towards this element of their working week i.e. time off in lieu (TOIL) should be taken out of educational time.

15. Is a trainee working under direct supervision (with a qualified GP in the room whilst consulting) doing clinical or educational work?

If the trainee is taking clinical responsibility for patient contact, regardless of the level of supervision, this is deemed clinical contact and should count towards this element of their working week i.e. TOIL should be taken out of clinical time.

16. What has happened to the red/amber/green supervision categories? Do trainees still need to do a certain amount of each?

The new guidance focuses on demonstration of competencies and purposefully doesn’t specify the type or level, or supervision required to achieve this. Pragmatically it would be anticipated that trainees start with direct supervision (GP and trainee in the same room while consulting) and move onto near supervision (GP in another room but same location as trainee while consulting). It would be expected that a trainee is confident, and has experience of, working in the UUSC setting independently without another clinician in the room during consultations prior to CCT.

Further to this it remains acceptable for trainees to work with remote supervision (GP and trainee in different locations i.e. one on visit and one at base) as long as the supervisor and the trainee agree that the trainee is experienced enough to work with this level of supervision. With the new guidance however there is no expectation, or requirement, that this is necessary to achieve competency and therefore CCT.

17. How does a supervisor and their trainee decide what level of supervision they should be working at on each shift?

At the start of each shift the supervisor and trainee should sit down to discuss the supervision level they both feel is appropriate. It is expected that the trainee will provide the supervisor with an updated copy of their training passport preferably before but at the latest at the start of each shift to support this conversation.

Following discussion, the supervisor and trainee will agree on a level of supervision. If there is any discrepancy between their wishes it would generally be expected that they would start the shift at the highest level of supervision requested, but then consider progressing to less supervision if both parties were happy following further discussions.

Factors to take into account are previous UUSC experience, level of supervision at in hours work at that time, familiarity with the provider set up/shift type/IT etc. The workload on the shift should not directly impact on the decision regarding supervision level given to the trainee i.e. if it is busy this is NOT a reason to relax supervision if it would not otherwise have been felt to be appropriate for that trainee.

18. What will happen if I don’t have my passport available to show my supervisor at the start of my shift?

It is expected that trainees will maintain their passport to be up to date and accurate and to share it with their supervisor on every UUSC shift. It is an excel document that is best viewed electronically so we would encourage storage in a location with easy access (e.g. in a folder of an email account). Alternatively, it would be acceptable to print it out in advance of a shift if there was concern about email or other access on site.

If a trainee did not have a passport to share with their supervisor before or at the start of the shift it is possible that this could lead to a compromise in the quality and level of training provided. In the absence of an updated passport the supervisor/provider reserves the right to alter the shift to enable them to feel comfortable with the trainee and their capabilities. As an example, this could include an increase in the level of supervision provided or as a last resort refusal for the trainee to work that shift.

19. Can CBDs, COTs and audio COTs be completed during an UUSC shift?

Work place based assessments should reflect the full scope of training. As a result, we would encourage trainees to complete a proportion of these assessment in the UUSC setting.

20. If hours are not being counted do trainees need to keep a record all UUSC work completed and if so how and where?

The UUSC log sheet (updated version of OOH log sheet) should still be completed by a trainee at the end of each UUSC shift. This form should then be signed by the UUSC clinical supervisor. The completed form should then be uploaded to the eportfolio as an OOH log entry.

21. How will a trainee demonstrate competency in UUSC?

There are six UUSC competencies that need to be demonstrated;
1. Ability to manage common medical, surgical and psychiatric emergencies
2. Understanding the organisational aspects of NHS out of hours care, nationally and at local level
3. The ability to make appropriate referral to hospitals and other professionals
4. The demonstration of communication and consultation skills required for out of hours care
5. Individual personal time and stress management
6. Maintenance of personal security, and awareness and management of security risks to others

Some elements of these could be achieved in routine or extended/improved access hours or duty doctor sessions in the trainees host practice. For example on the day triage, same day emergencies and some secondary care experience may lead to experience relevant to some areas of the competencies. It is however anticipated that other competencies will only be fully achieved through working shifts for an UUSC provider outside the practice.

It would be expected that to achieve competence trainees will have experienced working in all shift types including face to face (base shifts), telephone triage and visits. In most cases they will have experienced this in settings with access to patient records. If their Out of Hours provider doesn’t always provide this access, then they should demonstrate training experience of working without access to GP records. We recommend that evidence is collated in the form of assessments and learning log entries, collated in a competency record.

22. What does a trainee do if they have already done some OOH shifts under the previous guidance but will be assessed, and obtain CCT, after the new guidance is in place?

It is likely that any hours worked under the ‘old’ system will help trainees demonstrate the newly defined competencies anyway. We suggest that trainees midway through their ST3 year at the time of change-over discuss with their CS/ES what competencies they both feel have already been achieved and document this, perhaps with a note of hours worked to that point. After this the trainees would continue to document competencies, but no longer count hours.

Anyone entering ST3 after the introduction of the new guidance would be expected to follow new guidance and fully complete their competency log.

23. How will a clinical supervisor know how competent a trainee is when they work on shift together?

Trainees will own, and update, an UUSC passport that will provide training details and assessment progress. This will be stored alongside the competency record. Trainees will be expected to share this with their UUSC clinical supervisor before each shift to be used as a basis for discussion with the trainee at the start of each shift regarding their outstanding learning needs.

24. Is there any guidance on where I have to complete my UUSC work within Severn?

There are a range of shift options available to trainees to enable them to complete UUSC shifts and therefore demonstrate competency. Severn GP School would normally expect a majority of this work to be undertaken in the patch that the trainee is based for their training.

25. Who will decide if a trainee is competent?

The educational supervisor will review the passport and competency record, alongside discussion with the trainee regarding their experience in UUSC settings. Once satisfied the educational supervisor will sign off competence through the eportfolio/educational supervisors report (as they do currently).

26. What does a trainee do with the passport and competency record once it is completed?

Trainees should continue to add evidence to the competency record throughout their training to demonstrate that competence is maintained. Once complete it should be uploaded to the eportfolio before the final ARCP date and linked to a reflective learning log entry under the OOH heading so that it is easily visible to the ARCP panel (and your educational supervisor).

27. If an educational supervisor (ES) doesn’t themselves work in the UUSC setting, how will they be confident that the trainee is competent?

The competence record will detail the evidence which the trainee feels demonstrates attainment of each competency. If there is concern or uncertainty, then we would encourage dialogue between the trainee and ES. If further clarification is sought, we would encourage the ES to speak to the clinical supervisors working with the trainee or seek further advice from the GP School via their local TPD team.

28. Are there any resources available to help trainee’s development in UUSC work or for trainers to use in tutorials / trainers’ groups?

The GP School has produced some resources that can be used to help trainees reflect on their outstanding learning needs, or in tutorials or other educational settings during training. They can be found on our website.

29. I am unsure about the changes to the guidance and wonder if it might be better if it stayed as it is.

How do recently qualified GPs feel about the proposals?

We asked clinicians in the Severn area who were within five years of qualification what they felt about the changes and how they felt about their UUSC training. They provided us with the following reflections and quotes which may be helpful to new trainees.

“I would encourage trainees not to think about OOH as an onerous box-ticking exercise. The experience you can gain working alongside seasoned local GPs is really invaluable and I think falls under the umbrella of ‘not everything that counts can be counted’”.

“You might only really appreciate how much you can learn from them (clinical supervisors) once your training is done and you’re left to figure it out on your own. I saw patients and problems that I would not have encountered in my daily practice and learnt much more about problem-solving and working safely than I would otherwise have done.”

“OOH work is a difficult skill to learn and less exposure to it may make more trainees fearful of it.”

“Everything else is competency based in GP training. I see no reason why this should not be also.”

(time recommended in previous guidance) “felt about right. At time it felt like extra commitment to squeeze in around a busy day job, but it did force me to get experience in OOH.”

The Severn School of Primary Care acknowledges the potential conflict of interests for Educational Supervisors signing off competencies in IUC while also being asked to support release of trainees from practice work to undertake IUC shifts and are aware of this being flagged following the initial release of the new IUC guidance and FAQs. We have therefore added this additional information to provide clarity for trainers and trainees.

Trainers are being asked to release trainees from in hours work (through time off in lieu) to complete IUC shifts which can have consequences for their scheduling and surgeries. Some of the new competencies can be met through duty and urgent visiting shifts in hours so it is possible that an educational supervisor may prefer to encourage/support their trainee to meet IUC competencies in hours as much as possible. What are the views of the school on this conflict and is there any consequences of a trainer encouraging trainees away from working ‘out of hours’?

Whilst we have acknowledged that some competencies can be met through work undertaken during duty and urgent visiting shifts we do not believe that this can wholly replace experience of working in the IUC setting. The trainee is ultimately responsible for deciding the nature of the shifts and work they undertake to complete these IUC competencies and we would encourage trainers to support and encourage this, rather than dictate or direct themselves. Clearly in some situations this will include work undertaken ‘in hours’ which is acceptable. It is however expected that this will not form the majority of the work contributing to IUC competencies.

There are many factors - within the competencies and as part of general professional development as a complete and rounded qualified GP - that cannot be experienced in hours. These include, but are not exclusively; working in an unfamiliar environment/with variable colleagues, seeing patients outside of your normal ‘population’ with access to different services and care, patients who choose to seek advice in the IUC setting solely and the ramifications of these health choices, onward referral to a hospital service which is reduced due to being during non-standard working hours, unfamiliar computer system and many more.

The Severn School would therefore encourage trainees to look at their training as a whole and ensure that the choices they make, with the support of their trainers, allow them to get a full and rounded picture of all the work GPs do day to day. This will ensure they understand the pathways their patients will go through and allow them to gain experience of working in a variety of settings from which they can choose to work once qualified. Lack of exposure, and therefore possibly confidence, in any area of GP work could subsequently limit the options available to that trainee once qualified.

If a trainee felt that they were not being supported in the work they wanted to undertake due to pressures from schedules in hours then we would encourage them to discuss this with their trainer, TPD group lead or the IUC fellows. It remains the responsibility of the trainer to sign off the trainee as fully competent in IUC competencies at the final ESR and we ask that this is taken into consideration when planning the work to do in the preceding training year.