A sense of urgency

VISITORS to UK emergency departments in recent years might be surprised to discover general practitioners at work amongst the team of specialist hospital doctors and nurses. But as the focus shifts away from distinct primary and secondary care provision, and as health boards and primary care trusts (or CCGs) look for new ways to improve patient care while also saving money and reducing A&E admissions, GPs are playing an increasingly important role.

Opportunities in this field are varied and GPs with a special interest (GPwSIs) in urgent and emergency care can choose to work one or more sessions a week in a variety of settings from hospital A&E or pre-A&E care centres to community locations such as walk-in clinics and the provision of out of hours care.

Entry and training

Many GPs who choose to pursue a special interest do the additional training needed after their GP training, usually while continuing to work part time as a GP. This is still an option for emergency medicine however the training requirements for this specialty can be intense and trainees may find it more manageable to undergo specialist training before they move into GP training.

GPs interested in developing a special interest in emergency medicine (EM) can undertake ACCS (EM) training which is a two year programme (comprising EM, acute medicine, anaesthesia and ITU) which then runs into a third year of EM-specific training targeted at the MCEM examination and would allow trainees to enter an EM ST4 post.

Trainees seeking dual training have the option to stop EM training at the end of ACCS (year two) which would give them a lot of experience and core competences but would only entitle them to work at a junior level in emergency departments (EDs) in the future. By completing the third year and passing the MCEM this would open the door to a more senior middle grade level role.

The competences, training and accreditation required to become a GPwSI in this field are set out in Guidance and Competences for the Provision of Services Using Practitioners with Special Interests – Urgent and Emergency Care.

The document highlights the many GPs who are currently providing specialist services or clinical leadership who do not consider themselves to be special interest practitioners. The guidance says it is not intended to undermine these clinicians.

For those who wish to achieve GPwSI status within the formal framework, it advises that training can be acquired in several ways, including both practical and theoretical elements. Examples include experience of working in an ED, a recognised university course (i.e. Diploma in Urgent Care from Middlesex University), self-directed learning with evidence of completed tasks, undertaking a clinical placement or working under direct supervision with a specialist clinician. All GPwSIs in this area must also complete accredited specific consultation and communication skills training relevant to urgent and emergency care.

The British Association for Immediate Care (BASICS) also offers training in pre-hospital emergency medicine for GPs who go on to work alongside the paid emergency services, providing medical support at accidents or while patients are in transit to hospital.

GPwSIs are expected to maintain a personal development portfolio to demonstrate they are maintaining these competences and this would form part of the GP’s annual appraisal.

As well as demonstrating sound generalist skills (good communication skills, ability to explain risk and benefits of treatments) GPwSIs in urgent and emergency care will be expected to demonstrate skills in specialist areas including the clinical management of urgent and emergency conditions, provision of urgent care for the elderly, clinical management of children within urgent and emergency care services, and management and leadership.

In practice

GPwSIs in urgent and emergency care provide an important bridge between primary and secondary care and are often found in the ED either working alongside or within the acute care team. This work is typically carried out for at least one session a week, in combination with their day-to-day general practice duties. Service delivery models vary but a GPwSI may be tasked with attempting to extract patients already booked into the ED in a bid to find alternative treatment or care options. They may see and treat simple problems or attempt to see all walking patients including those who need hospital facilities such as X-ray.

The most successful services tend to be those where strong working relationships are developed with the existing hospital staff and where multi-disciplinary team members share ideas and learn from each other to improve patient care. With this approach it is likely that GPwSIs are fully integrated into the ED, sharing a common reception and operational processes.

Other hospital locations include urgent care centres, pre-A&E urgent care centres, minor illness clinics or A&E clinical assessment units.

GPwSIs in this field can also be found in community settings, manning urgent care centres, minor illness clinics, minor injury units, providing out of hours services, or working with the ambulance service aiming to treat patients in their homes. Whatever the role, it is clear that GPs pursuing a special interest in this field can look forward to a challenging and exciting career.

Joanne Curran is an associate editor of GPST

Q&A Dr Ewen Mcleod, full-time GP working part-time in Aberdeen Royal Infirmary. He is vice chair of independent charity the British Association for Immediate Care (BASICS) Scotland

What attracted you to a career in urgent and emergency care?

I decided to get involved in emergency medicine following my personal experience of an enjoyable and worthwhile training experience as a GP VTS (vocational training scheme) in Aberdeen, particularly in the emergency department (ED) of Aberdeen Royal Infirmary. This was followed by a further two years post-GP VTS both in the paediatric ED and adult ED. I made the move from an ATLS (advanced trauma life support) viewpoint to BASICS pre-hospital care under the guidance of the present medical director of BASICS Scotland, Dr Colville Laird. This was prior to taking up the post of rural GP 44 miles from Aberdeen.

What do you enjoy most about the job?

I most enjoy sharing my primary care experience and management with ED colleagues, including emergency nurse practitioners. As well as being BASICS Scotland vice chair, I am also the Scottish Ambulance Service lead and one of the medical consultants for the Sandpiper Trust who support the provision of pre-hospital equipment to doctors and nurses via BASICS Scotland. This equipment mainly takes the form of the Sandpiper bag which was designed to be a standardised portable and effective immediate care medical kit for doctors and nurses in remote parts of Scotland.

Are there any downsides?

The only downside is the distance I have to travel to reach my local ED.

What do you find most challenging?

The most challenging aspect is keeping abreast of departmental and specialist services policies and procedures as I only work one session per week.

What about the role has most surprised you?

I have been most surprised with the expression on the faces of both my primary care patients and ED patients when I admit to working in both areas.

What is your most memorable experience so far?

My most memorable experience was escorting an attempted hanging patient from my community with my local paramedic crew to my ED and being able to assist with his ED management through to admission to a secondary care bed. A journey very few of my GP colleagues can experience.

What advice would you give to a trainee GP considering a career in emergency care?

I would advise trainees considering a career to complete their GP VTS first and then undertake further time and training within their local ED. Membership of an organisation such as BASICS/ BASICS Scotland brings many resources and contacts vital to a healthy experience of both ED and pre-hospital care.