A Friday night in out-of-hours
Dr Stephen Bassett describes the challenges of managing a busy hospital-based out-of-hours service
Dr Stephen Bassett
Role Chair of the All-Wales GP Out-Of-Hours Providers’ Forum, and clinical lead GP out of hours at the Abertawe Bro Morgannwg University Health Board
Place of work Morriston Hospital, Swansea
Hours worked per week 50 (30 clinical and 20 managerial)
I check on family dynamics before getting ready for my Friday night shift. My wife is shouting herself hoarse at a Swansea City game, my younger daughter is out with friends, and the eldest is preparing an A-level essay. On occasions, balancing my home life and out-of-hours work is tough, but I’ve never missed a school event and I can enjoy the South Wales beaches in the daylight.
I make the 20-minute drive to Morriston Hospital where my out-of-hours service is based. This is one of the four sites across our health board, which together look after 650,000 patients, with 100,000 contacts per annum. We are two doctors short across the patch tonight, so I start planning workarounds.
I log in to Adastra, and look at the pending calls. The team has been working hard. Blessed with very safe and effective triage doctors, we deal with 50% of our calls by telephone, 40% by appointment and 10% by home visit. My service is leading the way by using telehealth initiatives, community nursing resource teams, emergency nurse practitioners and advanced paramedic practitioners, as well as GPs. I am also on the working group introducing a Welsh NHS 111, which differs from the English system because we’ve chosen a clinician-led service rather than relying on computer algorithms.
We have dealt with 90 calls already this evening, and will handle close to 1,000 over the weekend. After reviewing the work pending and shift arrangements, I feel calmer. We have three ST3s in, which is a stroke of luck. I send a few instant messages reminding everybody to collaborate on triage.
There are now 30 new calls waiting for callback. I pick several complex cases likely to result in home visits. We have no dedicated visiting doctor in the evenings, so unnecessary visits can be wasteful. Some calls across the rural Gower peninsula can take two hours.
A nursing home reports a suspected urinary tract infection. I take a detailed history over the phone. The staff report normal observations and a multiply positive dipstick; my patient is not vomiting but she is a little more confused than usual. A visit will add nothing, so I arrange for the staff to collect an antibiotic, and 90 minutes later, the woman receives her first dose. This is much faster than carrying out a visit, more evidence based and kinder than an admission.
Workload is building up. There are now only three GPs on for the whole patch. I recently reduced the number of overnight doctors in order to pay for enhanced weekend rates where cover was too thin. We’ve accepted several cases from the A&E department next door. I reallocate roles via email, then switch to seeing patients.
A stream of children with bronchiolitis is resulting in several admissions. A few are seriously ill - hypoxic and tachypnoeic. It’s challenging to have such a varied case including lots of sick children, but sorting out undifferentiated illness is the best job in medicine. It’s reassuring to have an excellent paediatric team only 200 yards away.
I visit the hospital co-ordination centre to check on the ambulance queues. Using the GP triage skills on our team to reassess pending admissions has proven our value to unscheduled care - I have access to ambulance calls and retriage several to help out the ambulance service. After this, I do a quick visit to verify that a patient has died.
The shift is coming to an end. The screens are clear. The morning team can start with a blank sheet, although it won’t stay like that for long.
I drive home, listening to Beethoven. I’ll get six hours of sleep and then I’ll be back for another evening shift. With my Thatcher gene, that’s more than enough.