Providing out-of-hours care to patients can pose considerable challenges for GPs, and each year the MDU sees a number of complaints and claims against doctors who deliver this service.

GPs will often not have prior knowledge of the patient, or access to their full medical records. A greater emphasis on telephone triage can present additional challenges in diagnosis and treatment, while a patient's expectations and anxiety levels may be high if they feel their condition is urgent.

However, there are various ways GPs working out-of-hours can minimise risk and avoid common pitfalls.

Delay in diagnosis

GPs often have to manage uncertainty and are generally well aware it's not always possible to rule out a serious underlying condition when assessed early on in an illness. However, it is important to review a previously made diagnosis if the clinical course does not proceed as expected and not to become fixed on the first diagnosis, whether made by you or another clinician.

History taking and examination

Undertake a careful history and appropriate examination, and make detailed records. This will help to show your management was of a reasonable standard. It is important to document the relevant negative findings, as well as the positive, in your history and examination - for example, the absence of neck stiffness in a febrile patient.

Communication

Be aware that communication issues may arise. The out-of-hours setting is unfamiliar, and patients are usually seen by a doctor they have not met before. Patients may be more anxious than usual, and they can't compare their experience to previous episodes of care.

Perceived rudeness is a frequent trigger for a patient or relative to pursue a complaint against a GP, most commonly when there has been an unforeseen adverse outcome.

Telephone triage

While this is an essential part of the patient assessment, it can present additional challenges in diagnosing and treating patients. Although calls are often recorded, make sure you record the same detailed clinical note that would be expected of a face-to-face consultation. Safety-netting advice often comes under scrutiny in claims; we advise you provide this in very clear terms and document it as comprehensively as possible.

Remote consultations

Patients may access out-of-hours healthcare through remote consultations made by telephone, video-link or online, depending on their needs and circumstances. If you do not have access to the patient's medical records, and have not previously seen the patient face-to-face, a careful assessment is paramount. You must also give the patient your name and GMC number if you are prescribing.

Before carrying out a remote consultation, it is important to obtain consent from the patient. You should inform them of any limitations of clinical assessment by remote consultation and also of any potential security risks associated with the consultation taking place via the internet. It is important also to make an assessment of the patient's capacity to make decisions about any treatment proposed.

Be aware that certain aspects of communication such as non-verbal cues may be lost which could lead to misunderstandings by the patient or healthcare professional.

You must ensure you carry out the consultation in an environment where you can maintain patient confidentiality. You may also wish to explain to the patient the importance of ensuring that they are somewhere private where details of the consultation cannot be overheard or seen by someone else.

Even with the best will in the world, technology does go wrong and doctors must ensure they have plans in place for a patient's treatment if the system fails. The GMC advises that doctors must, where necessary, examine the patient so there should be a system in place to arrange a face-to-face consultation where appropriate.

Home visits

While it's not necessary or practical to agree to every request for a visit, as with all consultations, it is important to make careful and full records of the conversation (which in some cases may be recorded) when deciding if a home visit is necessary. Again, it's essential to record your safety-netting advice in detail.

Records

If you don't have access to the patient's full medical records, you may need to go back to basics in assessing a patient's background as well as the presenting complaint.

You should make a written contemporaneous record for any remote consultation in the same way you would for a face to face consultation. For remote consultations, it may be advisable to make more detailed notes. For example, you should record the patient's consent to a remote consultation and summarise the information available to you at the time of the consultation

Management plan

Record your management plan and a note of the instructions given to the patient very clearly within your clinical record. It is also important to explain to patients or relatives the expected course of the illness and the likely response time for treatment to take effect. You may consider writing these down for the patient.

Complaint handling

If an adverse incident occurs, it is important to give the patient an explanation and apology as soon as possible. Adverse incidents should also be reviewed, perhaps through a significant event audit, to minimise the risk of a repeat error.

Minimising risk in out-of-hours consultations

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