NHS MEL(2000)32

Health Department
Directorate of Primary Care

NHS Management Executive
St Andrew's House
Regent Road

Dear Colleague



1. Attached is a revised and updated version of the National Framework of Standards for Organisations Providing Out of Hours Care which takes account of recommendations contained in the Review of GP Out of Hours Services published in October 1998.

2. Implementation of the Review's recommendations continues:

  • The Scottish Out of Hours Study Group have been working on a project to assess the quality and cost effectiveness of current out of hours services and they will report in the summer;

  • The Royal College of General Practitioners are developing an accreditation system for out of hours providers; and

  • The University of Edinburgh is developing a national patient satisfaction survey which will be available for use by all out of hours organisations.

This framework may therefore be subject to further revision once the outcome of these pieces of work are known.


3. Primary Care Trust Chief Executives are asked to ensure that copies of the framework are distributed to Out of Hours Co-operatives, deputising services and GP practices which operate a rota system for providing out of hours services.

Yours sincerely

Director of Primary Care


6th June 2000


For action
Chief Executives,
Primary Care Trusts

General Manager,
Island Health Boards

For information
General Manager, Health Boards

General Manager,
Common Services Agency


Enquiries to:

Susan Malcolm
Directorate of Primary Care
Room 75
St Andrew's House

Tel: 0131-244 2680
Fax: 0131-244 2621
email: susan.malcolm@scotland.gov.uk


Paragraph 19 of the Terms of Service for Doctors, as amended, sets out the responsibilities of a doctor who is making use of an organisation providing deputy doctors to ensure that the organisation provides a service which is adequate and appropriate for his or her patients. GPs will wish to ensure that any organisation providing out-of-hours care sets standards for the care which it provides, both to inform its members or subscribers of those standards and of its performance against those standards, and to allow it to audit its own activity.

This document sets out a framework against which locally appropriate standards should be defined, and includes brief guidance notes which should assist with that definition. Primary Care Trusts Boards and GPs should, in principle, apply the same standards to judging the performance of all forms of GP out of hours care.

GPs will wish to ensure that organisations set standards in relation to the following aspects of the care which they provide.

i. Competence of the Doctors on Duty

The competence of the doctors on duty is governed by the provisions of paragraphs 18, 19 and 20 of the Terms of Service for Doctors. In particular, paragraph 20(1) states that a deputy must be suitably experienced within the meaning of Section 21 of the National Health Service (Scotland) Act 1978 (other than by virtue of being a restricted services principal), or have the acquired right specified in regulation 5(1)(d) of the Vocational Training for General Medical Practice (European Requirements) Regulations 1994, or be a trainee general practitioner.

doctors on duty should be able to provide the full range of services normally provided by GPs out-of-hours.

ii. Adequacy of Service

Primary Care Trusts are required to ensure that any GP out of hours arrangement in their area includes appropriate arrangements to ensure quality and responsiveness of service. The number of doctors on active duty and their deployment should be adequate having regard to the emergency care needs of the population to be covered and the nature of the area. The organisation should specify to its members or subscribers the geographical area which it covers, for example, by using postcodes, or by reference to a map.

The organisation should inform its members or subscribers if it is no longer able to provide a service for whatever reason. As much notice should be given as the circumstances allow. Arrangements for handing back calls to participating practices during emergencies and crises should be set out clearly.

iii. Transfer of Clinical Information to and from a Patient's Own Doctor

There should be arrangements for the transmission to the patient's own doctor of written, faxed or e-mailed reports concerning the service provided to a patient, which should include the duty doctor's assessment and information about any treatment or necessary follow-up.

Reports should normally be made available to the patient's own doctor as soon as is reasonably possible. Where it is judged that the patient's own doctor might wish to take action more quickly, information should also be provided by telephone or NHSnet e-mail.

There should be arrangements for members or subscribers to supply duty doctors in advance with information about seriously ill patients or other patients with special needs. Any arrangements for handing back particular calls to members or subscribers should be set out.

iv. Supporting Staff Engaged by the Organisation

Members or subscribers should be advised of the nature of any supporting staff engaged by the organisation, and where and by whom those supporting staff are indemnified for their acts and omissions. Members or subscribers should also be advised of any protocols used by supporting staff.

v. Transport Arrangements for Doctors

Members or subscribers should be informed of the nature of any transport provided for the doctors on duty and of whether the doctors are accompanied by a driver.

vi. Communications with the Doctors Providing Clinical Care

The nature of the communication system or systems used by the doctors providing clinical care should be specified to the members or subscribers.

vii. Information

All organisations should have in place clear standards and systems for:

  • case recording, including hand-over to the daytime service and feedback to the patient's own GP;

  • confidentiality;

  • audit trails in case of questions or complaints

viii. Communications with Patients

All out of hours organisations should have a strategy to ensure that patients are clearly informed about access to out of hours care and how services are arranged and should look for regular opportunities to increase the patient understanding of their service. The organisation should specify how patients or their representatives are to access the service in an emergency, and whether an answering service or machine is used. Health Boards should ensure that no out of hours service in their area requires more than two telephone calls for patients to access it and that all such service providers are working towards contact via a single telephone call. Different arrangements may be appropriate at the beginning and end of shifts to avoid over-burdening of the out of hours organisation with calls intended for practices.

Services should have a clear policy for handling calls from telephone boxes which ensures that they are handled quickly.

The organisation should also specify how it will obtain patients' views on the service.

ix. Prioritising Cases

Organisations should establish clear protocols for staff answering calls. The protocols should include the responsibilities of staff in relation to responding to, prioritising and passing on calls. This may include guidance on what information to collect or on particular symptoms which require a quick referral to clinical staff. Where guidelines are used. organisations should ensure that their introduction, use and any changes are backed up by appropriate training.

x. Arrangements for giving Advice, for Primary Care Centre Consultations and for Home      Visiting

The organisation's operational arrangements should be set out. The increasing emphasis on evidence-based medicine across the NHS is as relevant to out of hours organisations as it is to other areas of the NHS and clinical guidelines on best practice in handling particular conditions, where they are available, should be used by clinicians in organisations to support and demonstrate consistent delivery of best practice. Where guidelines are used, organisations should ensure that their introduction, use and any changes are backed up by appropriate training.

xi. Recording of Requests for Care and of Action Taken

The organisation should record requests for care and the action taken in response to those requests, using a clerical or computerised system which can operate separately from the clinical records. This should allow the analysis of individual requests for care and the action taken in response, and would also enable appropriate analysis of aggregated data concerning demands on the service and responses to those demands. Any computerised system should if possible include a secure audit trail to prevent data erasure and to record the date, time and author of data entries and alterations.

xii. Vulnerable Patient Groups

The organisation should monitor particularly carefully their treatment of vulnerable patient groups for example, children, the elderly or the terminally ill, including the reasons for calls and the type of consultation given. The organisation should also make full use of the information gathered through reviewing complaints and critical incidents.

xiii. Working Patterns

It is important that all organisations have clear arrangements for back up cover in case of emergency. All organisations should have clear protocols which include trigger factors for calling additional help. Out of hours care is primarily a night time service, and many staff will also have day time commitments, organisations should therefore have policies which seek to ensure that the quality of care is not compromised by tired out staff.

xiv. Team Working

Regular multi-disciplinary meetings and discussions are likely to be particularly important to organisations given the use of a large and varying team. Organisations should also make full use of critical incident reviewing with staff so that the organisation learns from problems or complaints.

xv. Clinical Audit

Organisations should participate in systematic clinical audit and have systems of clinical governance which are consistent with those of local LHCCs and PCTs.

xvi. Review of Clinical Practice

All organisations should have systems in place for discussion and feedback on clinical issues between participating GPs.

xvii. External Relationships

Organisations should set out their arrangements for co-ordination with care provided by hospital accident and emergency departments, out of hours, Scottish Ambulance Service, community nursing, mental health and social work teams.

xviii. Complaints

Information should be collated concerning complaints about the service and any appropriate action taken following the investigation of those complaints.

Arrangements should be in place to ensure that doctors on duty and members or subscribers will co-operate with the patient's own doctor, to adhere to the national requirements of the NHS complaints procedures, in the investigation of any complaint made about the service provided, and that any appropriate remedial action is implemented.

xix. Remedial Notices

The organisation should collect information concerning remedial notices served by a Primary Care Trust, and any remedial action taken to correct identified service deficiencies.

xx. Accountability

As a matter of routine, each organisation should be able to report its performance on

  • the average and the range of waiting times in emergency centre

  • the average and the range of response times for emergency and non-emergency home visits

  • time taken to answer or return calls

  • patient satisfaction levels

  • adherence to administrative protocols

  • number, handling and outcome of complaints

All out of hours organisations should produce an annual report which should cover core data including workload, proportion of calls dealt with in different ways, patient response, performance against any standards or targets set and complaints. The annual report should be submitted to the relevant Primary Care Trust and be available to patients.