Dr Zaid Al-Najjar, a practicing GP and Medicolegal Adviser at Medical Protection, considers the risks that GPs should watch out for when undertaking out of hours (OOH) work.

In addition to my work as a Medicolegal Adviser at Medical Protection, I continue to work in general practice on a sessional basis, mainly in the OOH setting. The OOH service is contracted to provide patient care when day surgeries close so in most circumstances we cover evenings, overnights and weekends.

Working in OOH does present some unique challenges which is one reason why some GPs choose not to do it at all. As with daytime surgeries, OOH shifts are always very busy; however one of the main differences is that you often have no background history or prior knowledge of the patients, and in many cases, no access to previous medical records. Some other factors I have seen that can cause real difficulties and risks when dealing with patients OOH include:

• Working in an unfamiliar location and environment
• Patients who present to OOH tend to have injuries or illnesses of a more acute nature
• It is harder to refer the patient to secondary care and access to investigations and other services can be restricted
• There are fewer ancillary staff
• Cases can be more complex than those found in daytime general practice, with a higher proportion of vulnerable patients with urgent care needs
• Initial assessments are usually completed on the phone. 

There is also evidence to suggest that patients who present to OOH may be more likely to take action against a doctor they do not know if they experience an adverse event. Working at Medical Protection, I know all too well the importance of access to adequate indemnity for my OOH work and I advise GPs to let Medical Protection know their shifts and keep them updated on any changes.

During my time at Medical Protection, I have come across some recurrent themes relating to the risks of OOH work. These include:

• In many common presentations such as back pain, shortness of breath, chest pain, fever and headache, it is important to record whether red flags are present or absent. If something goes wrong and you attract a negligence claim or complaint, these will be looked for by the regulator or lawyers.
• Recording examination findings and safety-netting advice is also important. I have reviewed several cases where the doctor has said they examined a patient at home but did not record it, only to regret it later.
• OOH doctors can get caught out when verbal reassurance is given to a patient by a number of doctors and a sudden deterioration leads to an adverse outcome. My threshold for organising a face-to-face consultation or home visit is therefore much lower for patients who re-present to OOH not long after being treated by a doctor. 
• Assessing how urgently a patient needs to be seen. How soon does that home visit need to be carried out? Can the patient wait six hours? This can be difficult when there is no access to the patient’s records, but not arranging a review of the patient within an appropriate timescale can make a vital difference to the patient’s outcome.

In summary, working in OOH, or any unscheduled care environment, is a challenging, busy and potentially high risk environment to work in. As long as you are prepared for this and have received appropriate training in triage, it can be satisfying and a nice change from the management of more chronic conditions in daytime general practice.

Find out more

• Book onto one of our Clinical Risk Assessments for out of hours organisations.

Further reading

• Advocating your concerns in parliament
• Writing the visiting note: now, or maybe later?

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Please note: Medical Protection does not maintain this article and therefore the advice given may be incorrect or out of date, and may not constitute a definitive or complete statement of the legal, regulatory and/or clinical environment. MPS accepts no responsibility for the accuracy or completeness of the advice given, in particular where the legal, regulatory and/or clinical environment has changed. Articles are not intended to constitute advice in any specific situation, and if you are a member you should contact Medical Protection for tailored advice. All implied warranties and conditions are excluded, to the maximum extent permitted by law.