Many GPs work outside the standard surgery setting for either part or all of their working week. Some choose to work exclusively for OOH (Out-of-hours) services, others in addition to their practice role.

This guidance gives an overview of OOH workplaces, but please be aware that urgent and emergency care departments vary in structure and the nature of the work, so your local services may look quite different.

Contract

Employed

You may be formally employed by an OOH provider on a standard contract used by the whole organisation. The BMA has produced a model contract for salaried GPs, which it recommends all employers use.

If your employer is not using the BMA’s model salaried GP contract, the BMA advises that the contract offers terms no less favourable than the model contract.

If you are a BMA member and have recently been offered a contract, a BMA adviser can give advice tailored to your individual circumstances before you sign through our free contract checking service. The contract checking service can also be used for existing employment contracts.

There are a range of OOH service providers throughout the country. Some are private, others are NHS Trusts, ambulance services, federations or community interest companies. Not all services offer forms of engagement that are pensionable. The BMA is able to advise on how private contracts deviate from the model contract but cannot enforce any changes.

Self Employed

As a self-employed 'locum' GP, you may choose to have a contract for services with an OOH provider. Working as a locum can provide more flexibility for the individual or form the basis of a portfolio career. However, being self-employed means locum GPs cannot expect the same employment benefits as their salaried counterparts. Being self-employed in non-standard settings, such as OOH and urgent and emergency care, can present unique challenges, such as lack of peer contacts and professional isolation.

Some providers may offer zero-hours contracts and shifts organised through a bank or platform. This structure of shift or session assignment can provide flexibility, as employees are not obliged to perform a minimum number of hours, but also means that a GP may not have guaranteed work.

Your status as employed or self-employed should not affect your entitlement to superannuate your income if the provider can access the NHS pension scheme.

The BMA has more information on Pensions and IR35.

Pay

The contract offered by the employer should outline the rate of pay and how this is reviewed annually. The contract should also set out how any additional expenses, such as mileage, are paid and claimed. Any extra responsibilities, such as the supervision of trainees and necessary late finishes ,should have pre-agreed remuneration policies. It is always preferable for overtime to be agreed beforehand, rather than trying to claim it after the event.

The BMA recommends that all employers of sessional GPs implement the annual pay increase for salaried GPs as recommended by the DDRB. For GPs on the BMA model contract, a clause requiring the employer to implement the annual DDRB uplift is included.

Forms of OOH Work

Most urgent and emergency care (UEC) setups  include telephone consultations and face-to-face consultation in a centre or through home visiting. A driver and vehicle will usually be provided.

Shifts may be allocated to one type of duty or another, such as telephone consultations, face-to-face appointments or visits. In some settings you may be asked to work flexibly between these different roles.

Some OOH services also provide 'back fill cover' for localities and practices to enable protected learning shutdowns.

Flexible working

Some doctors may work OOH as a second role for a range of reasons: for example, to maintain NHS performers list links, retain face-to-face examination skills, or to perform a role which can be term-time only to meet childcare demands.

Some GPs are looking for the OOH role to support greater geographical mobility, as they often involve triage or telephone consulting shifts which can be done from various locations.

Urgent treatment centre

This involves seeing patients face-to-face or remotely in a clinic setting, often in a hospital or community hub. There may be individual or team appointment books, or a walk-in and wait approach. Patients may have been triaged by a clinician (possibly yourself or a colleague) prior to booking or could have been booked by 111. Clinicians may also handle calls from the 111 service between seeing patients.

If the setting operates a 'walk in' policy, patients may have come in to be seen without clinical assessment. In an urgent care setting, you should only be seeing patients with urgent medical needs. Some OOH providers offer Improved Access to GP Services (IAGPS) appointments, which are booked by surgeries and are for more routine consultations.

Certain settings may host services with different purposes and eligibility criteria for access and booking: for example, walk-in for urgent versus IAGPS, which are pre-booked by practices only. Sometimes these streams of patients may operate in parallel, for example when housed next to or within an A&E department. There may be an IAGPS, UTC and emergency department on the same site, with clear protocols for how patients are accepted, and on what terms they can be transferred from one to another.

Telephone consultations

These sessions may be worked from a hub or remotely from home if the IT support is available. OOH, 111, or GP practices and PCNs may offer telephone consultations.

In some roles, such as with 111, you may be triaging patients to a more appropriate place of care. This may be directing them to seek emergency treatment at the A&E department, arranging an appointment with a minor injuries unit, OOH or urgent treatment centre, or providing advice on self-management at home.

A telephone consultation is much more than telephone triage as it encompasses delivering a full episode of care (full assessment), advice and guidance, signposting, electronic prescribing where available, supporting other HCPs (such as paramedics on scene), admissions, as well as allocating UTC appointments and home visits.

Telephone consultations may sometimes require moving to video and use of text messaging to supplement communication. This development should be facilitated by the provider with the appropriate equipment and systems provided.

Some providers have GPs working with 111 and 999 call handlers to 'validate' ambulance dispositions. This is to help decide whether an ambulance is the most appropriate option for a patient, or whether they simply need transport but not medical assistance en route. If an ambulance is needed, the clinicians may be required to decide whether the urgency of the ambulance can be safely downgraded to a less urgent category, therefore allowing the ambulance service to prioritise an emergency response to those with life threatening, time critical conditions.

It is likely that the number of remote-only, non-geographic telephone consultation services will expand in the next couple of years. Video consultations are becoming increasingly popular due to the additional information provided by seeing the patient. The implication of remote consultations can be that you will be seeing a patient in a different area to yourself.

Therefore, referral pathways and prescription processes may be different, and it is important to be fully briefed on these (or where relevant information can be found) prior to the consultation. It is important to keep up-to-date with changes in all organisational clinical processes, especially where you may work more infrequently for a service. The service should have mechanisms for highlighting significant changes to you by newsletters with links to updated information.

Given the advent of the systems approach to UEC, it benefits GPs to understand the route into their service via NHS 111 pathways, and also to have some understanding of how the Directory of Service (DOS) operates. GPs who have previously worked exclusively in a daytime GP role may have little to no knowledge of these aspects of the UEC System. Local DOS services can be approached to provide orientation sessions.

Emergency departments and minor injuries units

Some GPs work alongside emergency medicine colleagues in emergency departments and minor injuries units. This may be ‘in hours’ or OOH.

GPs in emergency departments may see all emergency care patients or only those patients deemed to be requiring primary care, or they may work from the same queue as the rest of the emergency medicine team. GPs may operate within their GP CCT or may be operating under nominal supervision of the Emergency Medicine Consultant, but this structural decision is determined by the Trust. However, it is important to differentiate for indemnity purposes.

GPs in emergency departments may be required to 'queue bust', where the clinician facilitates investigations with the patient which may expedite them more appropriately. Alternatively, the GP may be required to 'stream', by rapidly identifying the correct services for the patient to be directed to within the department. GPs may also decide to restrict themselves to the minor injuries department.

Mobile and visiting

These GPs provide visits to housebound patients, according to clinical need. Visits are generally in patient’s own homes, care homes and community hospitals.

Palliative care is a frequent feature of OOH work, and decisions regarding treatment escalation need to be made without access to a patient’s Advanced Care Plan. In addition, mental health emergencies and social care issues may arise in OOH work which will need to be dealt with using the correct pathways and with relevant partners, such as the local authority and community mental health team.

You may be provided with a specially-equipped car and driver, or be required to use your own equipment and vehicle.

Caseload

For employed doctors, there is an expectation of set hours and an agreed set role within an organisation where there can be different roles, for example home or community visits, centre based, or home working. With consultation and mutually agreed adaptations, a clinician’s role may change while employed at the organisation.

Job plans are an important tool for limiting significant changes to a clinical role and should be agreed with your employer. A GP job plan usually includes clinical duties, administration, team meetings, any specialist roles and CPD time. The BMA has produced guidance for creating a job plan and can provide advice and support on broaching these with your employer.

If working to timed appointments, find out:

• if the rate per hour is realistic for the type of caseload if you are self-employed
• if you are able to rebook later appointments to accommodate complex cases (mental health, safeguarding) or if there is a mechanism for claiming overtime due to having to extend the planned session
• how much of the follow-on administration will fall to you and how much can be delegated to support staff: for example, obtaining missing clinic letters, completing complex referral forms, adding test requests to systems, completing forms requested by patients, such as insurance forms and TWIMC letters.
• whether additional paid admin time will be allowed to respond to complaints, to log SEAs or to attend SEA meetings. If working without a predefined clinic allocated to you, the employer should inform you of the rough expectation of consults per hour and what mechanisms are available to offer continuity to the patients you see who require a follow up appointment
• whether you will receive remuneration if you have to discuss a case with the Coroner’s Officer or complete a medical certificate of cause of death at a later date.

Access to patient’s medical record

Some UEC services provide the clinician with full access to patient’s medical records providing they use a Smart Card, whereas others only offer their stand-alone separate systems. This can make a consultation more difficult because you won’t know a patient’s history, medication, and previous management.

GPs working in these setting may also wish to review medical records after an episode of care for quality improvement activities and personal development purposes - for example, to find out the outcome of a case or admission. The organisation must provide reasonable support to its clinicians for these activities.

Prescribing

In theory, you should only prescribe for your patient’s urgent medical problem. In practice, there may be patients who have 'lost' their prescription, request 'maintenance methadone', have travelled without their regular medication, or encountered problems obtaining prescribed medication at the pharmacy. It is up to your clinical judgement whether to prescribe in these instances, and providers should have a robust prescribing policy covering these issues.

For further information on safe prescribing, please see the GMC guidance on prescribing and managing medicines and devices.

Use of electronic prescribing (EPS) rather than printed or even hand-written FP10s has revolutionised ease of prescribing in some areas.

On visits, it may be necessary to dispense medication, including if you are visiting a patient out of hours when a pharmacist is not available. It is especially important to check dose, type, course length and allergies in these instances and record all this in the patient’s notes, including batch number and expiry date. In certain instances, mainly End of Life Care, you may be dispensing controlled drugs. You will need to ensure you are aware of the national and organisational policies and regulations surrounding these. Some providers have a restricted drug formulary, which you will need to be aware of.

Equipment

If you are self-employed as a locum doctor or employed using a zero-hours contract, you may be expected to provide and maintain your own equipment (stethoscope, oxygen saturation probe, blood pressure machine). However, computer or laptops are usually provided by the organisation and subject to organisational information governance processes.

If you are formally employed by the organisation, you should expect all necessary equipment to be provided and maintained by your employer.

If equipment is provided by the organisation, it is important to know which member of staff is responsible for stock and maintenance of equipment so that in the event there are discrepancies, you are able to report these and rectify the situation. For example:

• is the equipment fit for purpose and of a suitable standard?
• is the equipment regularly cleaned and serviced if necessary?
• if required to do home visits, are the vehicles clean, well-equipped and suitable for use?

Information governance

It is important to establish who is responsible for information governance: the clinician or the provider. In some cases, the provider may offer or deliver mandatory information governance training, after which responsibility for maintaining GDPR will fall to the GP.

It is important to follow the GDPR rules put in place by the provider. It should be clear what processes should be followed in the event of a GDPR breach and who will be responsible for rectifying or reporting the issue if necessary.

The BMA has guidance for GPs on GDPR, to improve understanding of personal responsibility under the 2018 UK Data Protection Act.

Health and wellbeing

Working in an OOH setting can be particularly demanding, and the nature of the cases a clinician may be dealing with can be more complex than that of a traditional practice. Some examples of how to minimise the risk of complaints and create a more fulfilling workplace experience are:

• good history/examination/records
• good communication
• being willing to consider alternative diagnoses
• safety netting

If you are struggling with the pressures of working in an OOH setting, the BMA provides a free wellbeing and counselling service to members.

Safety

Clinician safety should be paramount, and when working in UEC there are some instances where the GP may be more at risk. The provider may have a lone worker policy which provides some protection, or guidance for these scenarios. If concerned about working in a certain scenario, clinicians should ask for a risk assessment to be undertaken.

If you are visiting a patient at home or outside of the provider setting and have been provided with a vehicle, the vehicle should be clean and well-equipped. It is good practice for the provider to mark the vehicle for easy identification and fit the vehicle with galley-lights to identify property names or numbers after dark. In some cases, it may be appropriate for your driver or the police to attend visits with the GP where there may be risks to the clinician’s safety.

If a visit is deemed high risk, you should be accompanied by appropriate support, for example the police or a social worker.

Supervision of AHPs and colleagues

As a GP you will be working as part of a team with a number of different healthcare professionals. You may be expected to provide clinical leadership and answer queries and questions. Providing informal support and supervision to colleagues is a part of most roles but any greater level of managerial responsibility should be agreed formally and remunerated appropriately. Similarly, training and ongoing learning may be necessary for formal supervisory roles.

Supervising trainees can be a rewarding experience and should be facilitated by your employer. Supporting trainees should be a formalised element of a clinician’s job role.

Working in OOH services can be a rewarding and fulfilling experience. Please contact the BMA with any queries or concerns you may have about a potential role or existing role in an OOH setting.