Out of hours
Correct as of April 2009
Summary
The general medical services (GMS) contract, implemented in April 2004, gave GPs the opportunity to opt out of providing out of hours (OOH) patient care. PCTs with health boards are responsible for commissioning and delivering OOH services.
Out of hours (OOH) care
Implementing risk management strategies (identifying and assessing the risks within the organisation and ways of delivering services) is paramount for providing and maintaining a quality and safe service to patients. Providers of OOH care must comply with guidelines set by NHS Quality Improvement Scotland (NHS QIS).
Improving safety in OOH providers
Risk management strategies are paramount to providing and maintaining a quality and safe service to patients. MPS advises OOH providers to undertake a comprehensive and facilitated risk assessment, in partnership with all service providers, to identify OOH service risks.
OOH providers must ensure that they have appropriate medical indemnity arrangements in place to cover potential liabilities arising from work undertaken by the organisation and its employees. There should be specific policies in place for high risk patient groups such as children, patients with mental health problems and patients receiving palliative care.
It is also important to have a robust mechanism in place for identifying patients who contact the OOH provider on more than one occasion over the same problem. Repeat contacts should trigger re-assessment of whether a face-to-face meeting is necessary to be able to exercise sound judgment about what is in the patients, interests.
There is the risk of misplaced reassurance when a patient has already been reviewed by one or more colleagues during a care episode. This is particularly relevant for those patients who have communication and/or learning difficulties.
Details of all OOH consultations should be sent to the practice where the patient is registered by 8am the following morning. If this is not done, the patient’s GP will be unaware of the OOH consultations and this may affect future care.
Common risks when working for an OOH service
It is unlikely that you will know the patient who contacts the OOH service, and you will probably not have access to their medical records, or their past medical and medication history. Any treatment decision will, therefore, be made solely on the information provided by the patient at the time of the consultation.
An effective discussion with the patient should ultimately result in a more informed and accurate diagnosis, which will reduce the risk of medical errors occurring. A breakdown in communication and inadequate patient management may possibly lead to a delay in diagnosis, with serious consequences for the patient. If your patient is a child, it is important to take into consideration the parents’ concerns. Parents are often good judges of whether or not a child is seriously unwell.
You should always make complete and contemporaneous medical records of all episodes of patient care, including home visits and telephone conversations. You should complete the medical records yourself and should not pass this responsibility on to an administrator.
Telephone systems
You may be required to undertake telephone triage. This involves making a decision on the seriousness of a case, based on the evidence provided by the patient over the telephone. Your OOH organisation may provide additional training before you take on telephone triage.
OOH organisations often use decision support software, and you will need to ensure that you are familiar with this. Ensure that you aware of the organisation’s policy on action you should take if you are unable to contact a patient who has requested assistance.
Issues to consider if you're thinking about OOH work
If you are considering OOH work there are certain issues that you should think about.
Training – training may be required on the computer software used by the OOH service, including how to identify when a patient has previously used the OOH service for the same episode of care.
Peer review – you should be prepared to have telephone conversations and consultations recorded and reviewed on a regular basis. Familiarise yourself with the organisation’s policies, including its patient safety incident report policy; its referral system; how it deals with test results; and how patient information is exchanged at the changeover of shifts.
Equipment – the OOH service may supply the necessary equipment – or you may have to supply your own. A thorough check of the functionality of equipment will be needed. You may be provided with a fleet car and driver; or you may have to use your own car; seek clarification.
The drugs policy – you need to find out whether or not the OOH service supplies drugs for home visits, and check the availability of drugs at the OOH centre. You will also need to find out if controlled drugs are provided by the OOH service or if the doctors have this responsibility.
Further information
- Price J, Haslam J, Cowan J, Emerging risks in out-of-hours primary care services. Clinical Governance: An International Journal Vol. 11 No. 4, pp.289-298, 2006
- The Publication of the Panel Report for the Serious Untoward Incident Investigation into the Death of Penny Campbell, May 2007
- NHS Quality Improvement Scotland 2004 – The Provision of Safe and Effective Primary Medical Services Out-of-Hours