Urgent & Unscheduled Care
(UUC & OOH)
Because 2am home visits don't come with a textbook — but this page almost makes up for it.
UUC is one of the most anxiety-inducing parts of GP training — and one of the most rewarding. This page gives you everything you need: what to do, when to do it, how to write it up, and how to actually perform well in the OOH setting.
📥 Downloads
Handouts, learning logs, OOH scenario packs, and teaching extras — ready when you are. Brilliant for pre-session prep and post-session reflection.
path: Urgent Unscheduled Care (including OOH)
- commissioner provider OOH contract.docx
- emergencies in brief - the canbury saq.doc
- emergencies in detail - urgencies and emergencies saq.doc
- ESAQ emergencies self-assessment questionnaire.doc
- learning log OOH form - bedoc.docx
- learning log OOH form - ram.docx
- learning log OOH form - yh deanery.docx
- ooh clinical supervisor - duties and feedback form.doc
- ooh clinical supervisor support package.doc
- scenario ooh - death.doc
- scenario ooh - frantic telephone call.doc
- scenario ooh - palliative care.doc
- systm one OOH manual.pdf
- training ooh workbook.doc
- training ooh workshop - 0 session plan.doc
- training ooh workshop - 1 emergencies.doc
- training ooh workshop - 2 organisation of OOH.doc
- training ooh workshop - 3 making referrals.doc
- training ooh workshop - 4 communication skills.doc
- training ooh workshop - 5 whats special about OOH.pdf
- training ooh workshop - 6 telephone triage.pdf
- training ooh workshop - 7 unscheduled care course workbook.doc
- uuc - on one side of A4.docx
- uuc - self assessment tool.pdf
- uuc - things to reflect on and consider.docx
- uuc - which level of supervision for which st stage of trainee.docx
- uuc learning log form - bvts.docx
- write up uuc - example 1.doc
- write up uuc - example 2.doc
A hand-picked mix of official guidance and real-world GP training resources — because sometimes the best pearls are not hiding in the official documents.
A busy trainee's guide to UUC in under 90 seconds. (We know you have a clinic in 10 minutes.)
UUC is not about clocking hours — it's about demonstrating capability across a variety of urgent care settings. Do both OOH and on-call duty doctor sessions. Write them up meaningfully against the 13 Professional Capabilities. Use the Bradford VTS learning form to guide your reflection. And don't leave it all to ST3 — you'll regret it.
It's not just a training requirement. It's what separates a good GP from a great one.
The reality of GP urgent care
Every GP — whether they do OOH or not — encounters urgent and unscheduled presentations every single day. The panicking parent with a febrile infant. The chest pain at the end of morning surgery. The 111 advice call at 6pm. UUC training teaches you to handle these moments calmly, safely, and confidently.
The skills learned in OOH — working with limited information, in unfamiliar settings, often alone — are precisely the skills that define safe GP practice.
Why trainees struggle with this
- OOH feels different — unfamiliar patients, unfamiliar systems, unfamiliar IT
- Working in relative isolation feels scary at first
- The "what if I miss something serious?" anxiety is real and normal
- Telephone triage requires different skills to face-to-face consulting
- ePortfolio write-ups are often weak — sessions done, learning not captured
- Trainees leave OOH sessions until too late in training
A trainee who has completed their UUC training well can handle a deteriorating patient calmly, make safe telephone triage decisions, know when to refer and when to manage, communicate clearly under pressure, work within an unfamiliar team, and document their learning meaningfully. That's the goal — not box-ticking.
More than just Out of Hours. Much more.
The Definition
Urgent = the patient needs to be seen soon.
Unscheduled = the patient has NOT pre-booked a routine appointment.
UUC covers all settings where patients present acutely — not just OOH centres. In your hospital posts, your on-call programme counts. In GP posts, it's OOH and in-hours on-call duty.
✅ Where you CAN get UUC evidence
Direct GP settings:
- On-call / duty doctor sessions in your GP practice
- Out of Hours (OOH) emergency centres
- OOH mobile home visit sessions
- Telephone triage sessions (OOH or in practice)
- GP centres attached to A&E departments
- Extended hours with acute/unscheduled presentations
Allied settings (supplementary evidence):
- A&E, Paediatric Assessment Units
- Medical Assessment Units (MAU)
- Psychiatry on-call
- Mental Health Crisis Team (observational)
- Gold Line / Palliative Care Urgent Services
- Paramedics & Regional Ambulance Services
- NHS 111 / 999 call handler observations
❌ What is NOT enough on its own
- Only doing in-hours on-call duty doctor sessions
You need OOH too — different skills, different context - Only doing hospital placements (A&E, MAU etc.)
These supplement but cannot replace primary care UUC experience - Doing OOH sessions but not writing them up
Hours without evidence = no ARCP credit - Extended hours appointments that are routine
Only counts if presentations are genuinely acute and unscheduled
✔ Prerequisites Before Doing Any UUC Work
When you're not sure what to do, start with the vitals. They will tell you how worried to be.
Always record the vitals. If they're abnormal, worry. When you're stuck, come back to the vitals — they cut through the uncertainty and help you make the right call.
| Age Group | Heart Rate (bpm) | Resp Rate (/min) | Notes |
|---|---|---|---|
| < 1 year | 110 – 160 | 30 – 40 | 🌡 Temperature: Normal 36.1–37.2°C. Concern if >38°C 💧 CRT (Capillary Refill): Normal <2 seconds 🩸 O₂ Saturations: Normal 95–100%. Below 90% = very worrying. For COPD patients: ask what their personal baseline is — may be 90–93% 📊 NEWS2: Consider scoring when sats, HR, RR, BP, consciousness, or temperature are abnormal. Score ≥5 = urgent concern. |
| 1 – 2 years | 100 – 150 | 25 – 35 | |
| 2 – 5 years | 95 – 140 | 25 – 30 | |
| 5 – 12 years | 80 – 120 | 20 – 25 | |
| >12 years / Adult | 60 – 100 | 15 – 20 |
A patient can look deceptively well despite abnormal vitals — especially the young and previously fit. And a frightened patient can have a falsely high HR. Trust the trends, not a single reading. If you're unsure, repeat the measurement and calculate NEWS2.
Spoiler: there are no new capabilities. You already know them. You just need to apply them in the urgent care setting.
The 13 Professional Capabilities (PCs) you know from your ePortfolio are grouped into 5 UUC Capability Areas for the purposes of UUC evidence. There are no separate "UUC capabilities." When writing up UUC sessions, write against the 13 PCs — and you'll automatically cover the 5 areas.
What to Write About — Click Each Area to Expand
👤 Y — You & Others (Fitness to Practice, Communication, Ethics)
Fitness to Practice
- How do you manage stress in an unpredictable urgent care environment?
- How do you handle multiple urgent demands simultaneously without crumbling?
- Personal security risks — home visits alone, aggressive patients, exposure hazards
- Security of colleagues, admin staff, and other patients in the waiting room
Communication Skills
Communication is a broad umbrella — remember it includes all of the following:
- Telephone consultation skills and telephone triage
- Breaking bad news in the OOH context
- Calming down the angry or distressed patient
- Exploring ICE and Patient Specific Outcomes (PSO) — what does this patient specifically want to be able to do?
- Negotiating with the patient around treatment or management decisions
- Motivational interviewing skills — helping patients reach their own conclusions rather than telling them what to do
- Self-help management advice — empowering patients to manage aspects of their own condition
- Handling carers, relatives, and families — especially common in OOH with elderly patients
- Data gathering skills — structured, systematic history-taking
- Person-centred care — understanding the patient's experience, not just their symptoms
- Skills for using the computer in the consultation — without it getting in the way of the relationship
Ethical Practice — Common OOH ethical dilemmas:
When you write about an ethical encounter, link it to one or more of these named principles — this is what demonstrates that you understand ethical practice, not just what you did:
- Patient Autonomy — the patient's right to make their own decisions
- Beneficence — doing good
- Non-maleficence — avoiding harm
- Justice / Fairness — fair distribution of care and resources
- Principle of Utility — the greatest good for the greatest number
- Rights-based ethics — every individual has an equal right
- Aristotle's principle of morality — to do the right thing; good people do good things
- Consent — informed, voluntary, capacity-based
- Confidentiality — and its limits
- Competence to make decisions: ability to understand information, retain it, weigh up pros and cons, and make a decision
- Gillick competence — for under-16s: can they understand the nature and consequences of the decision?
Link every ethical dilemma to a named principle (autonomy, beneficence, non-maleficence, justice). This shows you understand the theory behind the practice, not just what you did.
🔬 C — Clinical Knowledge, Skills & Decisions
Data Gathering — Be specific!
"Took a history and examined the patient."
"Dull right-sided chest pain, non-radiating, no SOB, no diaphoresis, no palpitations, happens at any time, not exertional, lasts >4h, no FH of IHD, 20 pack-year smoking history. Chest exam: air entry vesicular, bibasal creps L>R, RR 22, SaO₂ 96%, HR 88, apyrexial."
CEPS — Clinical Examination & Procedural Skills
- Document every examination finding with specifics
- For procedures: describe technique, equipment, asepsis, and outcome
- Good opportunity to get CEPS assessments signed off in OOH
Making Decisions & Clinical Management
- How did you make your diagnosis? What tools or scoring systems did you use?
- What clinical resources helped you? (NICE CKS, BNF, protocols)
- What decisions did you make and why?
- Were there any cases you needed to look up? What did you find?
🔄 C — Complex & Long-term Care (Managing Complexity, Working With Colleagues)
Managing Medical Complexity
Thinking complexity = number of conditions. Managing tonsillitis + ear infection + dry skin is NOT medical complexity. Managing COPD + heart failure where SOB has multiple possible causes IS.
- Juggling several not-straightforward conditions simultaneously
- Managing uncertainty — when you can't be sure of the diagnosis
- Discussing risk with patients in the OOH context
- Prescribing in patients with multiple conditions and drug interactions
Working With Colleagues
- Case discussions — who did you discuss with and what was gained?
- Referrals — to whom? What was the minimum dataset? Was it appropriate?
- What were the referral criteria? How did you decide this was the right threshold?
- Telephone referrals — did your CS listen in? How did it go? How could you have done better?
- Written referrals / letters — what did you include or not include? Was it concise? What did the CS think of it?
- Did anyone approach you for advice? What does that mean for your future as an independent GP?
- What does working with colleagues in the OOH setting look like, compared to your usual practice?
🏗 O — Organisation & Systems
Performance, Learning & Teaching
- What learning needs did today's session identify for you?
- What did you look up afterwards? (NICE, YouTube, BNF, e-GP?)
- Any courses or training you've decided to pursue as a result?
Organisation, Management & Leadership
- How do you prioritise when multiple urgent requests arrive simultaneously?
- How is the UUC service structured — IT, triage, governance?
- What training do OOH providers require of their doctors?
- How could OOH services be improved to meet changing population needs?
Organisation is a fantastic area to write about when sessions are quiet. Spend 20 minutes with your CS discussing how the OOH service is commissioned, quality assured, and organised. This is gold-standard reflective practice and produces excellent ePortfolio entries.
👥 P — Persons & Communities (Holistic Practice, Promoting Health, Community Orientation, Safeguarding)
Practising Holistically
- Effect of the problem on the patient's home, work, and social life
- Exploring ICE — what the patient thinks is happening
- The effect on their day-to-day function can itself be a red flag
Patient with "a bit funny vision for a few days." Doesn't sound urgent. Add: his husband brought him in as he nearly drilled through a colleague's hand at work. Now urgent. Context changes everything.
Community Orientation
Not just individual care — thinking about groups of patients with similar needs.
- Notice a pattern in what you're seeing? Create a leaflet, a YouTube video, a practice resource
- Rationing of care — protecting NHS resources for those who need them most
- Avoid unnecessary investigations for the same reason
Writing a one-liner saying you "referred a patient to a Community Counselling service" or a "Community Group" does NOT constitute good evidence of Community Orientation. You have simply referred an individual to an existing group — you have done nothing active to make care better for a community. The person who set up that group is the one showing Community Orientation.
Community Orientation is about actively extrapolating from individual patient encounters to improve care for a whole group. You don't need to set up a major new service — there are plenty of "quick wins." A short patient information leaflet, a pre-diabetes resource for your practice, a YouTube video for all patients with a particular condition — these are genuine examples. The more you think about it, the more you'll realise what you can do.
Promoting Health
Promoting Health is officially combined with Managing Medical Complexity in the RCGP's UUC framework. Personally, I think these two capabilities should be kept separate — the skills involved are quite distinct. I'd also suggest it should perhaps be called "Promoting Health and Positive Health" to better reflect what it encompasses. For now, write about both, but treat them as the distinct capabilities they really are.
- Do this at the right time — don't force it. Doing health promotion out of the blue in a sensitive or emotionally heavy consultation looks awkward and damages rapport
- You don't need to complete it all in one session — plant a seed lightly, and revisit it over future consultations
- Topics: smoking cessation, alcohol, hydration, diet, exercise, mental wellbeing and work-life balance
- Use motivational interviewing — ask questions to explore the patient's reality rather than telling them what to do. Patients are far more likely to act on advice they've reached themselves
You see a patient with new pre-diabetes. You spend real time educating them and working WITH them on diet. Or: you help a patient with her migraines, build real rapport, notice she still smokes, and lightly open that conversation — "There's something else I'd love to just mention briefly today..." That's health promotion done well — natural, timed, patient-led.
Safeguarding is included as a capability area for UUC work by the RCGP. There is, however, a genuine educational debate about whether safeguarding is truly a capability in itself — or whether it is better understood as a curriculum topic that, when done well, is simply the expression of other capabilities you already have (good data gathering, practising holistically, communication skills, working with colleagues). This question is worth raising in a tutorial discussion with your trainer.
In practical terms: provide evidence of your encounters and training in both adult and child safeguarding. Don't forget vulnerable groups — patients with learning disabilities, war veterans, homeless patients, sex workers, and others who face specific barriers to care.
This is where trainees lose marks. Doing sessions is necessary. Writing them up well is what actually counts.
The 4 Elements of a Great Reflective Log Entry
Step-by-Step — The Bradford VTS Approach
"Did OOH shift. Saw 8 patients. Chest pain, UTI, rash, knee pain, headache. All managed safely. Learning: I need to look up headache causes."
This tells the ARCP panel almost nothing about your capability.
"During tonight's OOH session I was challenged by a case that tested my Managing Medical Complexity capability. A 68-year-old with known COPD and CCF presented with acute breathlessness…" [continues with detailed data gathering, clinical reasoning, decision-making, uncertainty management, outcome and reflection]
Where you are on this ladder depends on your experience and your Clinical Supervisor's judgement — not yours alone.
At the start of every shift, sit with your CS and agree the supervision level. Share your updated training passport/evidence summary. If you disagree about the level — start at the higher (more supervised) level and progress during the shift if things go well. Never negotiate down if you're unsure. Patient safety is paramount.
Primarily a GP. When GPs are not directly on-site, qualified allied health professionals may contribute to supervision — but there must always be a named GP to whom escalation is possible. Allied health professionals must work within their own scope and must never seek medical advice from you (the trainee).
The right experience at the right time. Don't try to skip ahead — and definitely don't leave it all until ST3.
Building Your Foundation
- Discuss how UUC works — OOH structure, on-call models, different providers
- Attend OOH induction and orientation courses
- Sit in and observe telephone triage sessions
- Sit in and observe OOH face-to-face consultations
- Begin directly supervised sessions — see patients, but CS reviews before they leave
- Arrange observational sessions with community urgent services (mental health crisis, palliative care, ambulance service, 111)
- Build your smartcard access EARLY — it takes 2 weeks
Goal by start of ST3: Ready to work in a patient-facing capacity with nearby supervision
Developing Independence
- Months 1–2: Direct supervision → transition to nearby supervision
- Formal OOH provider induction if not yet completed
- See patients independently with CS immediately available on-site
- Complete a range of session types: telephone triage, face-to-face, home visits
- Experience a mix of evening, weekend, and overnight sessions
- Later: remote supervision if CS agrees you're ready (not required for CCT)
- Aim to cover all 5 UUC capability areas with good quality evidence
- Complete COTs/WPBAs in the OOH setting if CS is trained in WPBA tools
Goal by CCT: Demonstrated capability across all UUC settings. Good quality evidence in ePortfolio.
📊 NEWS2 — The Numbers You Must Know
| Parameter | Score 3 | Score 2 | Score 1 | Score 0 (Normal) | Score 1 | Score 2 | Score 3 |
|---|---|---|---|---|---|---|---|
| RR (/min) | ≤8 | — | 9–11 | 12–20 | — | 21–24 | ≥25 |
| O₂ Sats (Scale 1) | ≤91 | 92–93 | 94–95 | ≥96 | — | — | — |
| HR (bpm) | ≤40 | — | 41–50 | 51–90 | 91–110 | 111–130 | ≥131 |
| Systolic BP | ≤90 | 91–100 | 101–110 | 111–219 | — | — | ≥220 |
| Temperature | ≤35.0 | — | 35.1–36.0 | 36.1–38.0 | 38.1–39.0 | ≥39.1 | — |
| AVPU/GCS | — | — | — | A (alert) | — | — | V, P, or U |
- NEWS2 ≥7 = clinical emergency. Urgent escalation required.
- NEWS2 5–6 = urgent review within 1 hour. Consider HDU/ITU assessment.
- NEWS2 1–4 = monitoring and review. Minimum 4–6 hourly.
- New confusion/AVPU change always scores 3 — regardless of other scores.
- For COPD patients — use O₂ Sats Scale 2 (target 88–92%)
🦠 Sepsis — High-Yield Facts (NICE NG253, January 2024)
NICE updated their sepsis guidance in January 2024 (NG51 → NG253). The key change is that NEWS2 is now the primary risk stratification tool in adults (≥16, non-pregnant) in ambulance and acute hospital settings. AKT questions may test whether you know this distinction.
Definition (Sepsis-3):
- Life-threatening organ dysfunction caused by a dysregulated host response to infection
- Not just "infection + SIRS criteria" — Sepsis-3 moved away from SIRS in 2016
- Organ dysfunction = SOFA score change of ≥2
- In community/GP: qSOFA (RR≥22, altered mentation, SBP≤100) is a useful screening tool
Red Flag Sepsis Features (NICE NG253):
- New altered mental state
- RR ≥25/min
- New need for supplemental O₂ to maintain sats >92%
- HR >130/min
- SBP <90mmHg (or >40 drop from baseline)
- Non-blanching rash, mottled/ashen/cyanotic skin
- Not passed urine in 18h (oliguria)
Community/OOH Risk Stratification (NEWS2):
| Risk Level | NEWS2 Score | Action |
|---|---|---|
| Very Low | 0 | Review; safety-net; monitor |
| Low | 1–4 | Review within 1 hour; consider bloods |
| Moderate | 5–6 | Assess; consider urgent transfer |
| High | ≥7 (or <7 with single parameter = 3 + clinical concern) | 999 + pre-alert hospital |
Early Management (NG253):
- IV antibiotics: broad-spectrum within 1 hour for high-risk; may defer up to 3 hours for moderate-risk to gather microbiology
- Fluids: initial bolus 250ml isotonic crystalloid (Hartmann's preferred; 0.9% NaCl as alternative); up to 1,000ml total; reassess after each bolus
- Rural/remote: if transfer >1 hour, GPs should have mechanisms to give IV antibiotics pre-hospital
- Call 999 AND pre-alert receiving hospital simultaneously for high-risk features
These groups may not mount the expected fever or tachycardia — maintain clinical suspicion even with "reassuring" vital signs:
- Elderly — may not mount fever; confusion may be the only sign
- Immunosuppressed (steroids, chemotherapy, anti-TNF) — blunted inflammatory response
- Pregnant women — physiological tachycardia and leukocytosis at baseline
- Infants — may present only with poor feeding, irritability, reduced tone
- Beta-blocked or dehydrated patients — may not develop tachycardia despite haemodynamic compromise
📞 Telephone Triage — Key Clinical Facts
The '3-part' telephone triage decision:
- Immediate 999: Life threat — collapse, chest pain + diaphoresis, anaphylaxis, stroke symptoms, seizure not resolving, severe difficulty breathing
- See within hours: Potential serious illness but clinically stable — febrile child under 3 months, suspected UTI in diabetic, possible fracture
- Routine / self-care: URTI, mild musculoskeletal pain, minor skin complaints, early UTI in well adult
AKT High-Yield — Triage Traps:
- Infant under 3 months with fever (>38°C) = must be seen — cannot telephone manage
- Headache + fever + photophobia / rash = suspected meningitis → 999
- SOB + pleuritic chest pain = PE until proven otherwise — see urgently / A&E
- "Funny turn" in elderly = possible TIA — see same day, 2-week stroke service referral at minimum
- Testicular pain in young male = testicular torsion until proven otherwise → A&E immediately
- Back pain + bilateral leg weakness / bowel-bladder symptoms = cauda equina → 999/A&E
❤️ ACS — Red Flags, Decision Table & Atypical Presentations
ACS Red Flags — AKT High-Yield:
- Chest pain lasting >20 minutes
- Radiation to arm, jaw, or back
- Diaphoresis (sweating) or vomiting
- Cardiovascular risk factors (DM, HTN, smoking, FH)
- Pain at rest or on minimal exertion
AKT Decision Table — Time Since Pain (NICE CG95):
| Presentation | Action |
|---|---|
| Current acute chest pain (ACS suspected) | 999 ambulance immediately; aspirin 300mg chewed; do NOT delay transfer for ECG |
| Pain-free now, but pain within last 12 hours | ECG immediately; if normal → same-day urgent hospital referral; if suggests ACS → manage as above |
| Pain 12–72 hours ago | Clinical assessment + ECG; refer urgently same day |
Pain-free within 12 hours + normal ECG = still requires same-day urgent hospital referral. "Normal ECG, safe to discharge" is the wrong answer.
- Diabetic patients — autonomic neuropathy masks ischaemic pain; may present with weakness, syncope, or confusion rather than chest pain
- Elderly patients — may present as breathlessness, nausea, or syncope only
- Women — less likely to describe classic crushing chest pain; more often present with fatigue, jaw pain, back pain, or nausea
- AKT questions specifically target these atypical presentations — always maintain ACS in the differential for these groups
🧠 Head Injury — NICE CT Criteria (Must Know)
NICE guidelines specify CT head within 1 hour if any of the following are present in adults:
- GCS <13 at any point since injury
- GCS <15 at 2 hours after injury
- Suspected open or depressed skull fracture
- Any sign of basal skull fracture (haemotympanum, "panda" eyes, CSF leakage, Battle's sign)
- Post-traumatic seizure
- Focal neurological deficit
- More than 1 episode of vomiting
- Age ≥65 + any loss of consciousness or amnesia
- Coagulopathy + loss of consciousness or amnesia
The question often gives "ONE episode of vomiting" — this alone does NOT meet CT criteria in an adult (it requires more than 1 episode, or other features). However, ONE episode in children is taken more seriously. Read the vignette carefully.
In primary care: if any CT criteria are met → send to A&E immediately. Document the reason clearly.
🫁 PE — Wells Score & The D-dimer Trap
Wells Score — Key Thresholds:
| Score | Interpretation | Action |
|---|---|---|
| ≤4 | PE unlikely | D-dimer → if negative, PE excluded; if positive, imaging |
| >4 | PE likely | Immediate imaging (CTPA) — do not do D-dimer |
Wells Score Components:
- Clinical signs of DVT — 3 pts
- PE more likely than alternative — 3 pts
- HR >100 — 1.5 pts
- Immobilisation ≥3 days or surgery in past 4 wks — 1.5 pts
- Previous DVT/PE — 1.5 pts
- Haemoptysis — 1 pt
- Malignancy — 1 pt
Most GPs will refer directly to A&E when PE is suspected. Wells Score helps you articulate your reasoning in the referral. If Wells ≤4 and you have access to rapid D-dimer — use it. If not — refer.
🧒 Child with Fever — Red Flags You Must Know
High-Risk Red Flags — Immediate Action:
- Non-blanching rash — meningococcal disease until proven otherwise → 999
- Reduced or altered consciousness
- Grunting respirations or significantly raised respiratory rate
- Severe respiratory distress — nasal flaring, intercostal recession, tracheal tug
- Poor feeding in infant — especially under 3 months
- Pallor, mottling, ashen, or cyanotic skin
- Fever in under 3 months (temp >38°C) — always see face to face; cannot manage by telephone
- Bulging fontanelle (in infants)
- Prolonged capillary refill time (>2 seconds)
The AKT loves to present a child who "looks well" with a reassuring history — and then bury one red flag (e.g. grunting, or a purple spot on the skin). The right answer is always to act on the red flag, regardless of how well the child looks overall.
- Any non-blanching rash + fever
- Febrile infant under 3 months
- Any child with signs of sepsis
- Any child where you are clinically unsure — if in doubt, send
⚠️ AKT Traps Table — The Four Classic Mistakes
These four scenarios appear repeatedly in AKT questions. The distractor answers are seductive — and wrong.
| Scenario | ❌ The Trap Answer | ✅ The Correct Answer | Why |
|---|---|---|---|
| Chest pain — possible ACS | "Try GTN first and see if it helps" | 🚨 Admit immediately, aspirin 300mg, call 999 | Response to GTN does not rule in or rule out ACS. Normal ECG also doesn't rule it out. |
| Suspected PE | "D-dimer immediately" | ✅ Calculate Wells Score first. If >4 → direct to imaging, not D-dimer | D-dimer is useless at high pre-test probability. It doesn't exclude PE if Wells is high. |
| Sepsis features present | "Start oral antibiotics" | 🚨 Admit for IV antibiotics, fluids, monitoring. Call 999 if red flag sepsis. | Oral antibiotics are inadequate in sepsis. Delay = deaths. |
| Sudden severe headache | "Most likely tension headache / migraine" | 🚨 Rule out subarachnoid haemorrhage — thunderclap onset = SAH until proven otherwise | "Worst headache of their life" / "thunderclap" = CT head urgently. Never assume migraine without excluding SAH. |
AKT questions almost always give you a reassuring clinical picture with one red flag buried in the vignette. A patient who "looks well," "seems stable," or "has had this before" — but has BP 85, or a non-blanching rash, or a thunderclap onset. Always act on the red flag. The distractor answers are designed to capitalise on your relief at the reassuring details.
🧠 UUC Dangerous Diagnoses — The "Must Not Miss" List
| Presentation | Must Not Miss Diagnosis | Red Flag Features + Action |
|---|---|---|
| Headache | Subarachnoid haemorrhage, meningitis, temporal arteritis | Thunderclap onset ("worst ever"), neck stiffness, fever + rash, visual symptoms in over-50s. CT negative in first 12h → lumbar puncture needed for SAH. |
| Chest pain | ACS, PE, aortic dissection, tension pneumothorax | ACS: diaphoresis, radiation. PE: pleuritic, haemoptysis. Aortic dissection: tearing/ripping chest/back pain, differential arm BPs, aortic regurgitation murmur. |
| Abdominal pain ± collapse | Ectopic pregnancy, AAA, appendicitis, mesenteric ischaemia | Ectopic: any woman of reproductive age + abdominal pain + collapse — do NOT wait for positive pregnancy test. Pulsatile mass = AAA. |
| Back pain + neurological | Spinal cord compression, cauda equina, aortic aneurysm | Back pain + bilateral leg weakness + urinary retention / saddle anaesthesia = emergency MRI. Do not send home. |
| Limb pain/swelling | DVT, compartment syndrome, necrotising fasciitis | Calf warmth/swelling; severe pain out of proportion, pale/pulseless, woody swelling + fever + rapid skin spread. |
| Fever + rash + meningism | Meningococcal meningitis / sepsis | Non-blanching petechiae or purpura = 999 immediately. Give benzylpenicillin 1.2g IM/IV before transfer (unless confirmed penicillin allergy). |
| Mental state change | Hypoglycaemia, sepsis, stroke, subdural haematoma, delirium | Any acute confusion — check BM immediately. Fluctuating course = delirium until proven otherwise. |
| Arm/leg weakness, slurred speech | Stroke / TIA | FAST+ (Balance, Eyes, Face, Arms, Speech, Time). TIA: aspirin 300mg immediately, urgent TIA clinic same day, DVLA notification (stop driving), ABCD2 score to guide urgency. |
| Fever in oncology patient | Neutropenic sepsis | Temp ≥38°C in patient receiving chemotherapy = oncological emergency. Call oncology team immediately. Do not treat as routine infection. |
| Young woman + collapse + haemodynamic compromise | Ectopic pregnancy, anaphylaxis, arrhythmia, DKA | Do not anchor on one diagnosis. LMP, pregnancy test, BM, ECG, anaphylaxis trigger all needed. |
Questions often present a "reassuring" clinical scenario with one red flag detail buried in the vignette. Read every detail. The AKT tests whether you recognise the one item that changes the "safe to manage at home" answer into "refer immediately."
💉 Anaphylaxis — Diagnosis & Management (Resus Council UK 2021)
Diagnosis — Clinical, Not Lab-Based:
- Sudden onset, rapid progression
- Involving airway AND/OR breathing AND/OR circulation problems
- Usually with skin/mucosal changes (urticaria, flushing, angioedema)
Urticaria and angioedema alone do not constitute anaphylaxis. You need airway/breathing/circulation involvement. This distinction is regularly tested.
First-Line Treatment:
- IM adrenaline 500 micrograms (0.5ml of 1:1000) — outer mid-thigh
- Repeat every 5 minutes if no improvement in ABC
- Call 999 immediately
- Position: lying flat with legs raised (or sitting up if breathing is compromised)
- High-flow oxygen
- IV access + fluids if available
- Chlorphenamine 10mg IM/slow IV — antihistamine, use after adrenaline
- Hydrocortisone 200mg IM/slow IV — for protracted cases
- These do not replace adrenaline — they supplement it
Symptoms may recur 1–72 hours after initial resolution. Warn all patients. All patients must receive an adrenaline auto-injector before leaving and be referred to allergy services.
At discharge — must provide all 5:
- Information on signs/symptoms of anaphylaxis
- Explanation of biphasic reaction risk
- Auto-injector device training (demonstrate use)
- Trigger avoidance advice
- Referral to allergy clinic
🧠 Delirium / Acute Confusional State — AKT Must-Know
Key concept: Delirium is a medical emergency — not a psychiatric diagnosis. It is explicitly listed as an AKT testing area.
Clinical Features:
- Acute onset (hours to days) with fluctuating course — hallmark
- Impaired attention and consciousness
- Hyperactive — agitated, restless, aggressive
- Hypoactive — withdrawn, quiet, sleepy — often missed; mimics depression
- Mixed — fluctuates between both types
- Dementia = biggest single risk factor; but delirium can occur without it
Hypoactive delirium is the most commonly missed subtype — the quiet, withdrawn patient is easier to overlook than the agitated one. When in doubt about chronic vs. acute confusion: treat as delirium first.
Screening Tools:
- 4AT — quick, validated for primary care; score ≥4 = probable delirium
- CAM (Confusion Assessment Method) — requires Feature 1 (acute onset/fluctuating) + Feature 2 (inattention) + either Feature 3 (disorganised thinking) or Feature 4 (altered consciousness)
Differential Diagnosis — AEIOU TIPS (see Memory Aids for full mnemonic):
| Category | Key Examples |
|---|---|
| Infection | UTI, pneumonia, meningitis, sepsis |
| Metabolic | Hypo/hyperglycaemia, hypo/hypernatraemia, uraemia, liver failure |
| Neurological | Stroke, SAH, subdural haematoma, post-ictal |
| Cardiovascular | MI, arrhythmia, cardiac failure |
| Drugs | Opioids, benzodiazepines, anticholinergics, alcohol withdrawal |
| Endocrine | Hypothyroidism, Addisonian crisis, hypercalcaemia |
Blood glucose (immediately), FBC, U&E, LFTs, TFTs, CRP, MSU, blood cultures if sepsis suspected, 12-lead ECG, CXR. Do not wait for results before referring if clinically unstable.
⚡ First Seizure Management — AKT High-Yield
First Fit in Adults — GP Action Pathway:
- Generalised tonic-clonic: lamotrigine, levetiracetam, or sodium valproate
- Focal seizures: lamotrigine or levetiracetam first-line
- Sodium valproate: MHRA restriction — must NOT be prescribed to women of childbearing potential unless on the Pregnancy Prevention Programme (PPP)
- First-line: buccal midazolam 10mg in adults (5mg if age ≥10 years); rectal diazepam as alternative
- Maximum 2 pre-hospital doses (including any given before your arrival)
- Call 999 immediately; IV lorazepam is hospital first-line
💊 Emergency Drugs in GP / Doctor's Bag
There is no single mandated list — GPs must make a clinically defensible decision based on their setting (urban vs. rural). CQC cannot be 100% prescriptive. AKT questions test clinical reasoning about drug choice, not rote memorisation.
| Drug | Dose | Indication | Route |
|---|---|---|---|
| Adrenaline 1:1000 | 500 micrograms (0.5ml) | Anaphylaxis | IM (outer mid-thigh) |
| Aspirin 300mg | 300mg | ACS | Oral (chewed) |
| Benzylpenicillin | 1.2g | Meningococcal meningitis/sepsis — before transfer | IV or IM |
| Hydrocortisone | 100–200mg | Anaphylaxis, acute asthma, adrenal crisis | IV or IM |
| Chlorphenamine 10mg | 10mg | Anaphylaxis (adjunct) | IV or IM |
| Buccal midazolam | 10mg adult; 5mg if ≥10yrs | Status epilepticus | Buccal |
| Glucagon 1mg / GlucoGel | 1mg glucagon | Hypoglycaemia | IM / buccal |
| GTN spray | 1–2 puffs sublingually | Angina (NOT to "test" ACS) | Sublingual |
| Salbutamol | 2.5–5mg nebulised | Acute asthma / COPD | Inhaled / nebulised |
| Naloxone 400 micrograms | 400 micrograms | Opioid overdose | IM or IV; repeat every 2–3 mins PRN |
In suspected meningococcal disease (fever + non-blanching rash + meningism), give benzylpenicillin 1.2g IV/IM before transfer unless there is a confirmed penicillin allergy. Do not wait to arrive at hospital. Time is critical.
🏢 OOH Structure & Contractual Knowledge
- OOH is defined as work between 18:30–08:00 on weekdays, plus all weekend and public holidays (GMS Contract definition)
- Extended hours before 08:00 or after 18:30 does NOT count as OOH experience if it's part of your usual contract
- RCGP does not mandate a specific number of OOH sessions — it's capability-based
- Many trusts have a contractual requirement of ~6 sessions per 6-month GP post (paid as salary uplift)
- Contractual compliance ≠ capability sign-off. You still need quality ePortfolio evidence.
- Working Time Directive: max 40h/week average (6-month rolling); 11h rest between shifts; 20-min break in shifts >6h
🏗 The 5-Step UUC Consultation Framework — What Examiners Are Looking For
In a UUC SCA, examiners are not testing your knowledge — they are testing your safety, structure, and decision-making under pressure. This framework applies to both telephone and face-to-face urgent consultations.
Don't start with a full social history. Open with urgency assessment. "Tell me what's happening." Then screen for red flags before going deeper.
Onset, severity, red flags, functional impact. You have limited time in UUC — gather what you need to make a safe decision, not a complete academic history.
Say your clinical reasoning out loud: "Based on what you've told me, I'm concerned this could be something serious." Examiners need to hear you recognise the risk — they cannot mark what's only in your head. This is where most candidates lose marks.
Admit / Same-day review / GP manage / Advice + safety-net. Be decisive. Examiners want to see you lead — not hedge indefinitely.
Named symptom + named timeframe + named action. Then check understanding: "Do you know what to do if things worsen?" Safety-netting is the last line of defence — make it count.
You are not being tested on clinical knowledge. You are being tested on safety + decision-making under pressure. If you remember only one thing: Recognise risk early → Say it out loud → Act → Safety-net clearly.
📞 The Telephone Triage Consultation — What Examiners Look For
Structure of the telephone assessment:
Common candidate errors:
- Asking closed questions from the start — missing the patient's narrative
- Failing to ask about any red flags for the presenting complaint
- Making a disposition decision without adequate safety-net information
- Not clarifying who you're speaking to (patient vs carer vs bystander)
- Reassuring too quickly without adequate assessment
- Forgetting to confirm the patient understands the safety-net plan
- Not asking about the patient's own ideas or level of concern
🏠 The Home Visit Consultation — Different Rules Apply
Before you arrive:
- Know who you're visiting and why — review any available notes
- Personal safety — inform your driver or the OOH centre of your whereabouts
- Check your equipment bag — drugs, examination kit, prescription pad
- Know who to call if you need help (clinical and physical)
At the visit:
- Full vitals first — before you get distracted by the presenting complaint
- Environment tells you a lot — medications visible, carer present, home condition
- Consider safeguarding concerns — especially in frail elderly or child visits
- Have a low threshold for calling 999 if you're unsure
What examiners look for in OOH home visit SCAs:
- Systematic safety assessment — vitals before anything else
- Appropriate escalation decision-making
- Communication with patient AND family clearly
- Clear safety-net with specific written instructions where possible
- Patient-centred approach — even in urgent situations
- Ability to manage complexity (multiple conditions, limited info)
Examiners want to see that you can maintain patient-centredness even when working quickly. A brief "I can see this is very worrying for you" takes 3 seconds and scores marks.
⚖️ Managing Uncertainty in UUC — The SCA Goldmine
OOH consultations are often uncertain. Limited information, unfamiliar patients, no previous notes. This is exactly what examiners test — not just your clinical knowledge, but your ability to communicate and manage under uncertainty.
- Explicitly acknowledge uncertainty honestly
- Explain your reasoning process to the patient
- Give a specific action plan with clear triggers for escalation
- Check the patient understands and can follow the plan
- Empower the patient — "you are right to ring if..."
- False reassurance ("I'm sure it's nothing")
- Vague safety-netting ("come back if you're worried")
- Failure to explain why you're uncertain
- Making a confident definitive diagnosis with insufficient information
- Avoiding the patient's concern about what might be wrong
🚨 Prioritisation in Busy OOH Shifts — What Examiners Want
Some SCA cases test your ability to prioritise when presented with multiple problems or a complex urgent situation. Examiners look for structured, safe, patient-centred prioritisation.
- Address the most immediately dangerous issue first
- Acknowledge other concerns explicitly — "I want to address your chest pain first, and then we can talk about..."
- Don't ignore a red flag to complete a social history
- Ask "Is there anything else worrying you that you'd like me to know before we start?" — opens the hidden agenda early
- Time management in the OOH setting is a capability — demonstrate it
⏱ The 12-Minute SCA Structure for Urgent Cases
The standard 12-minute SCA structure applies to urgent cases — but with modifications. The Clinical Management domain is the highest-weighted. Running out of time before making a decision is the most common mark-losing error.
Clarify the presenting problem and what the patient wants. In urgent cases: pick up on alarm features immediately — "describe the breathing to me now." Don't spend a minute on social pleasantries.
This is NOT a full clerking. Target what changes management. Establish vital signs verbally on phone: "Can they speak in full sentences?", "Is the breathing laboured?" Verbalise your working diagnosis at around minute 6.
State the plan early and clearly: "I'm arranging an ambulance right now." Explain why urgent action is needed. Involve the patient/relative where possible. This is where most marks are won or lost.
Specific triggers and timeframes. Who to contact and how. Confirm understanding: "Do you know what to do if X happens before help arrives?"
🎯 Common SCA UUC Case Types — Know These
These case types are well-established in SCA and trainer reports. Knowing the pattern before you enter the room gives you a significant advantage.
Recognise TIA risk immediately. Do not agree to a "routine" visit when TIA is possible — always re-triage based on your own clinical assessment, not the paramedic's framing.
Key: ABCD2 score, DVLA notification, aspirin 300mg now, urgent TIA clinic same day.
Exclude SAH (thunderclap onset, maximum intensity at onset) and meningitis. Examination is expected. CT can be negative in first 12 hours — lumbar puncture is the diagnostic test.
Ectopic pregnancy, anaphylaxis, arrhythmia, DKA — all in the differential. Do not anchor on one diagnosis. Examination is expected. Check LMP, BM, ECG, anaphylaxis trigger.
Exclude sepsis using traffic-light system. Resist remote management if concern is high. Under 3 months with fever = face-to-face assessment, not telephone management.
This is a capacity assessment case. If the patient has capacity: respect their decision, document risks explained, escalate safety-net. If they may lack capacity: formal assessment required — best interests ≠ medical best interests alone (MCA 2005).
❌ Additional Candidate Errors — From Examiner Reports
- Agreeing to "routine" when it's urgent — downgrading urgency because the paramedic/caller uses the word "routine." Always re-triage based on your own independent clinical assessment.
- Devolving management — "I'll refer you to the duty doctor / triage nurse / paramedic team." The examiner wants you to make the decision. You are the doctor in the room (or on the call).
- Missing capacity when it's relevant — an elderly patient refusing admission is a signal to assess capacity formally. Do not simply override the patient, and do not simply capitulate.
- Using stock consultation phrases generically — "That must be very difficult for you" said at a predetermined point without responsiveness to the patient's actual cues. Examiners specifically note this as formulaic.
- Failing to verbalise the diagnosis — clinical reasoning that stays in your head is not assessed. Say out loud: "What I think is going on is..." This is the most commonly cited hidden examiner expectation.
- Too much history, not enough management — spending 9–10 minutes on information-gathering with only 2 minutes for management. The Clinical Management domain is the highest-weighted. This costs marks heavily.
📞 Telephone Consultation — Specific Rules & Safety Principles
Challenges unique to telephone consulting:
- No visual cues — must compensate with targeted verbal questioning
- Tone of voice, pacing, and pauses carry more weight than in person
- Document call contemporaneously: note it's a telephone call, any technical difficulty, who was present, follow-up agreed
- Urgency and the patient's affect are independent — a calm voice does not mean a safe clinical situation
If a patient has consulted remotely twice for the same problem and no diagnosis has been made — the third consultation should be face-to-face. This is both a safety principle and a medico-legal one.
Third-party consultation (relative calling about patient):
- Clarify who you're speaking to and their relationship to the patient
- Gather as much clinical detail as possible through the third party
- Try to speak to the patient themselves if at all possible
- Lower your threshold for face-to-face assessment — you have even less information than usual
- Always document who you spoke to and their relationship
Trainees from backgrounds where a calm affect signals safety may misjudge telephone urgency. In UK general practice, a patient who "sounds fine" may still be seriously unwell. Use systematic verbal red flag screening regardless of how they sound.
Phrases that actually sound human — tested in real clinics, not written by committee. Read once, use tomorrow.
🧩 Named Consultation Templates — Adaptable Frameworks
🧩 Template 1 — Urgent Telephone UUC
- Open: "Is [patient] safe right now — breathing okay, conscious?"
- Immediate red flags: 3–4 targeted questions to exclude life-threatening diagnosis
- Gather context: what happened, how long, relevant PMH/medications
- Triage decision + verbalise: "Based on this, I think... and I'm going to..."
- Explain plan: who, what, when, why
- Specific safety-net: triggers for 999, what to expect if improving
- Confirm understanding: "Do you know what to do if X happens?"
- Close: "I'll arrange [action] now. Call back if anything changes."
🧩 Template 2 — Face-to-Face Urgent with Possible Admission
- Open: "Tell me from the beginning — what's brought you in?"
- Red flags excluded: ask and document
- Clinical reasoning aloud: "I'm thinking this could be... because of..."
- Examination (targeted, report findings back to patient)
- Decision: "I think you need hospital today" OR "Safe at home if..."
- Shared decision / capacity check: understanding and consent
- Safety-net: specific + tiered
- Handover: what you'll communicate to the receiving team
Wisdom drawn from hundreds of OOH shifts, thousands of trainees, and more than a few near-misses. Professionally curated, candidly delivered.
When OOH is quiet, most trainees sit around feeling guilty. The ones who do well use it. Walk over to admin. Sit with the triage staff. Ask your CS to walk you through how the session is commissioned, how triage scores are audited, how handovers work. You'll get better ePortfolio material from a quiet session with a good discussion than from a busy one you didn't reflect on.
When you're uncertain whether to escalate — ask yourself: "What would I do at 2am if I were the only doctor available?" This single question cuts through consultation anxiety and gets you to the right answer faster than any framework. If the honest answer is "I'd call 999" or "I'd send them in" — that's your decision. Trust it. Act on it.
This is also a brilliant SCA technique. Trainees who are hesitant to escalate often become decisive once they apply this filter.
This is said everywhere and ignored everywhere. Smartcard setup for OOH systems can take up to two weeks. Do it the day your clinical supervisor tells you it's time to start OOH. Not the week before your first session. Not the day before. Two weeks. Consider yourself warned.
Experienced OOH GPs are sometimes frightened by telephone triage — because the stakes are high and you cannot examine the patient. The trainees who develop this skill well do three things: they ask systematic red flag questions for every presentation, they close with a specific safety-net, and they never give telephone reassurance about something they're not clinically confident about.
Almost every trainee arrives at OOH feeling anxious. This is not a sign you shouldn't be there. Appropriate anxiety keeps you careful and systematic. The trainees who struggle are often the ones whose anxiety makes them freeze, or the ones who have none. Both extremes are a problem. If you find yourself routinely too anxious to function — speak to your trainer or TPD early. There is support available, and addressing it early makes a real difference.
A recurring pattern among trainees referred at ARCP is not that they failed to attend — they attended, but their entries read like duty rosters rather than capability evidence. Every entry should make an ARCP reviewer think: "This doctor clearly understands what they're doing and why." Use capability headings. Use clinical reasoning. Use feelings and critical reflection. Make them want to sign you off.
The drunk and aggressive patient at 2am. The carer who insists the confused elderly woman is "just tired." The teenager who won't tell you what they took. These are not the cases to hurry through — these are the cases that will appear in your ePortfolio and your exam preparation for decades. Lean into them. Reflect on them deeply. They are where capability is built.
On mobile sessions, the driver is not just a taxi. They're part of the team. Brief them. Ask them what they observed when they went to the door. They sometimes know things you don't. And make sure they know where you are at all times — this is personal safety, not fussiness.
These are the real insights from trainees who have reflected honestly on what went wrong. They're uncomfortable to read — which is exactly why they're useful:
- "I didn't realise I had to say my clinical reasoning out loud. I was thinking it — but examiners can't hear your thoughts."
- "I thought being cautious meant not escalating. I didn't understand that caution sometimes means sending someone in."
- "I spent 8 minutes gathering history and ran out of time before I made a decision. The consultation had no endpoint."
- "I said 'see how it goes' — and didn't realise that's a fail phrase in urgent care."
What examiners actually expect — the hidden curriculum:
- You must declare the risk — not just recognise it privately
- You must lead the consultation — not follow where the patient takes it
- You must take responsibility — say "I think" and "I'm going to" — not "we could consider possibly..."
Every trainee has made at least three of these. Now you don't have to.
One of the most common — and most stressful — mistakes in GP training. By the end of ST3, you have AKT revision, SCA preparation, prescribing review, MSF, PSQ, and your final ARCP all competing for time. Starting UUC in your first GP post and spacing it throughout is not just good advice — it's self-protection.
An entry that lists patients and their diagnoses tells the ARCP panel you attended. An entry that reflects on clinical reasoning, capability development, and learning tells them you're growing as a doctor. Guess which one leads to sign-off.
In-hours duty doctor sessions are valuable — but they are explicitly not sufficient on their own. You need OOH experience to demonstrate that you can work with limited support in an unfamiliar environment. This is tested directly at ARCP.
"Come back if you're worried" is not a safety-net. A safety-net has three parts: a specific symptom to watch for, a specific timeframe, and a specific action. "If the pain spreads to your chest or left arm before tomorrow morning, call 999" — that's a safety-net.
Your practice needs advance notice (usually 4–6 weeks) to adjust the rota for your time off in lieu (TOIL). Turning up to morning surgery after an overnight OOH shift — because you didn't tell them — is both unprofessional and a Working Time Directive issue.
Non-attendance at a booked OOH session without reasonable notice is considered a professional offence by HEE GP Schools. It's equivalent to not turning up to your surgery. Always give maximum notice if you need to cancel. Always try to swap first.
A quiet shift where nothing happened and nothing was discussed with the CS produces no capability evidence and requires a repeat session. A quiet shift with a structured CS discussion about OOH governance, ethics, or clinical reasoning can produce excellent evidence. Make every session count.
A&E, MAU, and paediatric assessment unit experience is valuable supplementary evidence. But it doesn't replace the specific learning of OOH primary care work — particularly working in relative isolation, managing with limited resources, and navigating unfamiliar IT systems.
🚫 Unsafe Assumptions in UUC — The Six That Get Doctors Into Trouble
These are the assumptions behind many missed diagnoses, delayed escalations, and medico-legal cases. Recognise them before you make them.
Paramedics can and do mis-triage. You must always re-assess independently. Accepting another clinician's framing of urgency without your own clinical evaluation is a medico-legal risk. The SCA exam specifically tests this — do not downgrade urgency because a caller used the word "routine."
Elderly patients, those on beta-blockers, and dehydrated patients may not mount a tachycardia despite haemodynamic compromise. Always consider the full clinical picture. A normal heart rate does not exclude sepsis in these groups.
Panic attack is a diagnosis of exclusion. Hypoxia, arrhythmia, PE, anaphylaxis, and hypoglycaemia can all mimic panic disorder. Never make this diagnosis in UUC without first excluding these causes, particularly in new presentations.
Ectopic pregnancy, myocarditis, anaphylaxis, DKA, and PE do not respect age or previous health. Youth and fitness are not protective. This assumption has caused deaths. Treat the presentation, not the demographic.
Affect and acuity are independent. A septic patient may be calm because they are deteriorating into hypoactive delirium. Anxiety correlates poorly with clinical severity. Use objective findings — not the patient's apparent composure — to guide your assessment.
Nitrofurantoin has poor systemic bioavailability and does not treat bacteraemia. An elderly patient who remains or becomes confused after starting nitrofurantoin may have untreated systemic infection. This is a scenario that appears both in real practice and in AKT questions.
⚖️ Safety-Netting — The Medico-Legal Reality
Safety-netting was introduced by Roger Neighbour (1987) as a core component of every GP consultation. It is now one of the most commonly cited issues in MDDUS and MPS cases involving missed diagnoses in primary care.
✅ What Your Safety-Net Must Include
- The likely course if your working diagnosis is correct
- Specific symptoms that would suggest the diagnosis is wrong
- A clear action to take and an explicit timeframe (call 999 / call surgery / come back within X hours)
- Confirmation the patient understood — ideally ask them to repeat it back
📝 What You Must Document
- The safety-net advice you gave — in specific terms, not "advised to return if worse"
- Evidence that the patient understood — "patient able to repeat back..."
- Contact details confirmed — especially important in OOH
- That the call was a telephone consultation (if applicable) and who was present
Three remote consultations for the same unresolved symptom without a diagnosis = face-to-face assessment required. This is a safety principle and a medico-legal standard.
Tired doctors make mistakes. The Working Time Directive protects you and your patients. Know your limits.
- Normal surgery: 09:00–16:00 (7h)
- OOH session: 18:00–midnight (6h)
- Total: 13h — within limit
- Next day: late start at 11:00 to maintain 11h rest from midnight
- Or: use personal study session as post-OOH rest time
- Overnight shifts work best on Saturdays (rest both before and after)
- Midnight–08:00 on a weekday = cannot start work until 19:00 the following day
- Always tell your practice manager in advance — they cannot guess your OOH rota
- Aim for a mix: evening, weekend, and overnight sessions
NHS indemnity covers a lot. But not everything. And in OOH, the gaps matter.
🛡 Strongly Advised — Additional Personal Indemnity
NHS indemnity is provided for GP trainees undertaking UUC/OOH, but there are other professional activities that may not be covered. Personal membership of a recognised medical defence organisation (MDO) is strongly advised.
Before your first OOH session, contact your MDO and ask specifically:
"Does my current membership cover Urgent, Unscheduled, and Emergency Care work during GP training?"
Most standard MDO memberships for GP trainees do cover UUC — but double-check. Don't save a small amount of money now and face a large legal bill later. And remember: do not do OOH whilst on maternity leave, OOP, sick leave, or during a hospital post — your indemnity may not be valid.
The mental shortcuts that make UUC manageable. Commit these to memory before your first OOH shift.
The 5 Vitals — Always First
🔴 SICK vs NOT SICK — The Instant Clinical Triage
Before you gather history, before you think about differentials — run this rapid check. If any SICK feature is present, it changes everything.
| Feature | 🔴 SICK — Act now | 🟢 Likely NOT SICK — Monitor with caution |
|---|---|---|
| Vitals | Abnormal — HR >130, RR >25, SBP <90, O₂ <92%, Temp >38 or <36 | All within normal range for age |
| Behaviour / Consciousness | Altered, confused, not responsive as expected, GCS change | Alert, oriented, engaging appropriately |
| Pain | Severe (7–10/10), sudden onset, worsening rapidly, unusual quality | Mild to moderate, stable, consistent with known history |
| Progression | Rapid deterioration over minutes to hours | Stable or slowly evolving over days |
| Appearance | Pale, mottled, ashen, cyanotic, diaphoretic, not well-perfused | Colour normal, comfortable-looking, well-perfused |
In any urgent or unscheduled consultation, screen for red flags before you take a full history. A two-minute red flag check at the start of every UUC consultation is more valuable than a thorough social history at the end of one. If a red flag is present — act on it immediately, then complete the history.
🛡 The Safety Triad — Every Safety-Net Must Have All Three
A safety-net missing any one of these three components is incomplete. "Come back if worried" fails all three — it's vague about risk, vague about action, and has no timeframe.
The UUC Good Entry Framework — ICFE
The OOH Consultation Checklist
- Vitals taken and documented
- Presenting complaint — full history with red flag screening
- ICE explored — what does the patient think is happening?
- Relevant background — medications, allergies, relevant PMH
- Examination — appropriate and documented with specifics
- Diagnosis / differential — with reasoning stated aloud
- Management plan — clear and shared with patient
- Safety-net — specific symptom + timeframe + action
- Follow-up — who, when, where
- Documentation — contemporaneous, clear, complete
📋 SBAR — Handover Framework for Referrals & 999 Calls
Use SBAR every time you call an ambulance, refer to secondary care, or hand over to a colleague. It is the gold standard for urgent clinical communication in the NHS.
In the SCA, verbalising your SBAR elements during a referral or escalation scores marks in the Clinical Management domain. "I'm thinking sepsis because of X and Y, so I'm calling 999 now" is exactly the kind of statement examiners mark positively.
🧠 High-Yield Mnemonics for UUC — Commit These to Memory
DEFRAG — Urgent Triage Framework
Use at the start of every urgent UUC consultation
ALTERED — Sepsis High-Risk Features
Any one of these = 999 + pre-alert hospital
SAFER — Telephone Triage Safety Decision
Run through this before closing any telephone consultation
CUBE — Capacity Assessment (MCA 2005)
All 4 must be present for capacity to be intact
🧠 AEIOU TIPS — Differential Diagnosis of Acute Confusion
Use when you see acute confusion in UUC. Always exclude organic causes before considering psychiatric. Delirium is a medical emergency — not a psychiatric diagnosis.
Alcohol withdrawal, Addisonian crisis
Epilepsy (post-ictal), Electrolytes (Na, Ca, glucose)
Infection — UTI, pneumonia, sepsis, meningitis
Opioids/other drugs, Oxygen deficiency (hypoxia)
Uraemia, Underperfusion (cardiac failure, stroke)
Trauma — head injury, subdural haematoma
Intracranial — stroke, SAH, encephalitis
Psychiatric — rare first presentation; always exclude organic cause first
Structural/surgical — urinary retention, bowel obstruction
The UUC tutorial is one of the most educationally rich you'll do all year. Here's how to make it count.
Common Trainee Blind Spots
- Writing sessions up as narrative rather than capability evidence — correct this early
- Equating "doing 18 sessions" with having met UUC requirements — clarify the capability model
- Thinking "on-call duty doctor" covers all UUC needs — explain what's missing
- Treating OOH as a box to tick rather than a learning opportunity
- Failing to explore ICE in urgent settings ("no time") — this is exactly where ICE matters most
- Managing Medical Complexity = number of diagnoses — this is the most common conceptual error
Tutorial Ideas & Discussion Prompts
- "Tell me about a UUC case that made you uncertain — what did you do with that uncertainty?"
- "What's the difference between Managing Medical Complexity and just managing two things at once?"
- "Walk me through your safety-netting for the last OOH patient you managed by phone."
- "What would you do if you found your patient to be Gillick competent but clearly at risk?"
- "How did the OOH experience change how you see on-call duty in the practice?"
- Use the BVTS OOH scenarios (downloads above) for structured case-based discussion
As trainer, your role is to ensure the trainee has enough quality evidence in their ePortfolio to satisfy the ARCP panel — not just that they attended sessions. Review their UUC entries early (not the week before ARCP). Challenge vague entries. Ask for the clinical reasoning. A trainee with poor UUC evidence reflects not just on them, but on the educational supervision they received.
Three carefully constructed clinical cases — each with hidden learning points — and four reflective questions to take into your next tutorial.
🩺 Clinical Scenarios
📋 Scenario 1 — Confused 78-Year-Old After UTI Treatment
A daughter calls at 10pm. Her 78-year-old mother has become confused and agitated over the past 3 hours. She was diagnosed with a UTI two days ago and started on nitrofurantoin. She is also on metformin and ramipril.
Key questions to ask:
- What observations can you get over the phone — is she rousable, speaking normally?
- What is her baseline cognitive function — is she known to have dementia?
- Does she have a temperature? Can you measure it?
- Is there a rash, laboured breathing, or reduced urine output?
- How is she behaving — agitated and hyperactive, or withdrawn and quiet?
- Has anyone been with her to monitor her today?
- This is likely delirium on a background of inadequately treated UTI — but sepsis must be excluded first
- Nitrofurantoin has poor systemic bioavailability — it does not treat bacteraemia. If systemic infection was missed, she may have untreated sepsis
- Hypoactive delirium is the most commonly missed subtype — the withdrawn/quiet patient is easier to overlook than the agitated one
- Do not assume the confusion is simply from the infection being "slow to respond" — the trajectory has worsened
- Face-to-face assessment is required — do not manage acutely confused elderly patients by telephone alone
The trainee who says "she's on antibiotics, so it'll settle" fails this case. The correct decision is to arrange face-to-face assessment and screen properly for sepsis. The nitrofurantoin point is the AKT trap embedded in this clinical scenario.
📋 Scenario 2 — Paramedic Requesting Routine Visit for Arm Tingling
A paramedic calls requesting a "routine visit" for a 55-year-old man who has had right arm tingling for 4 hours. He is feeling better now, and the paramedic sounds relaxed and unhurried.
Key questions to ask:
- FAST symptoms — facial drooping, arm weakness, speech problems?
- Any visual disturbance, balance problems, or swallowing difficulty?
- Duration — exactly when did symptoms start and resolve?
- PMH — AF, hypertension, diabetes, previous TIA or stroke?
- Current medications — anticoagulants? antiplatelets?
- Is he currently driving or planning to drive?
- This is a TIA until proven otherwise — do not accept the paramedic's framing of "routine"
- Calculate ABCD2 score to guide urgency of TIA clinic referral
- Start aspirin 300mg now unless contraindicated
- Arrange urgent TIA clinic same day / next day
- Notify patient: stop driving immediately; inform DVLA
- This case type appears in SCA — the key skill is re-triaging independently of the caller's framing
📋 Scenario 3 — Young Woman: Sweating, Light-Headed, Rapid Pulse
A 30-year-old woman presents to the OOH centre. She looks unwell — sweating, light-headed, and has a rapid pulse. She has no specific complaint other than "feeling terrible." She came alone.
Key questions to ask:
- LMP and contraception — when was her last period and what contraception is she using?
- Any chance of pregnancy — including ectopic risk (IUD, previous PID, tubal surgery)?
- Any possible anaphylaxis trigger — foods, medications, insect stings?
- Blood glucose — any symptoms of hypo or hyperglycaemia?
- Cardiac history — any previous arrhythmia, palpitations, or syncope?
- Abdominal pain or shoulder tip pain — right-sided, sudden?
- Do not anchor on one diagnosis — ectopic pregnancy, anaphylaxis, arrhythmia, and DKA are all in the differential
- Ectopic pregnancy: any woman of reproductive age with haemodynamic compromise and abdominal pain — do not wait for a positive pregnancy test
- Examination is expected and essential in this scenario
- Full vitals immediately — do not take a lengthy history before assessing haemodynamic stability
- Have a low threshold to call 999 while you are still assessing
💭 Reflective Questions for Your Next Tutorial
These questions are designed to be used in ES meetings and tutorials. They don't have single right answers — they're designed to provoke honest clinical and professional reflection.
1. When in an OOH session, how do you decide whether a patient can be safely managed remotely or needs to be seen face-to-face? What factors tip your decision — and are there any you know you tend to underweight?
2. How would your management change if a patient calling at 2am sounded completely calm, but described symptoms that would concern you in a different context? What does this tell you about your reliance on affect as a proxy for acuity?
3. Have you ever accepted a referring clinician's framing of urgency without re-evaluating it yourself? What prompted you — or didn't prompt you — to re-assess? What would have needed to be different?
4. How do you communicate to an anxious relative that you are calling an ambulance for their loved one without creating panic? What phrases work for you, and what have you found makes it worse?
The questions that come up every year, answered honestly.
How many OOH sessions do I actually need to do?
The RCGP does not mandate a specific number. It's capability-based — you need enough evidence across all 5 UUC capability areas. As a practical guide, think of approximately 48 hours minimum. Some deaneries suggest 72 hours. Many trusts have a contractual requirement of 6 sessions per 6-month GP post (paid as salary uplift). If your contract states a number, that number is mandatory regardless of capability evidence.
Remember: contractual compliance ≠ capability sign-off. You need both.
Can I count on-call duty doctor sessions towards my UUC requirements?
Yes — in-hours on-call duty doctor sessions can contribute to your UUC capability evidence and can be logged under the UUC clinical experience group in your ePortfolio. However, they cannot replace OOH sessions. You need both. OOH provides the specific experience of working in relative isolation, in an unfamiliar environment, often with limited access to patient records and supporting services — capabilities that cannot be demonstrated from in-hours work alone.
Can I count my A&E / hospital placement experience?
Yes, but as supplementary evidence only. Hospital experience (A&E, MAU, Paediatric Assessment Units, Psychiatry on-call) can contribute to the 13 Professional Capabilities in the UUC context — but only if there is focused discussion between you and your clinical supervisor explicitly linking it to the UUC capability areas. Simply noting that you "worked in A&E" is not sufficient. This hospital experience should NOT replace OOH and in-hours GP on-call work.
What happens if I'm LTFT (less than full time)?
The same rules apply. UUC requirements are capability-based, not hour-based. There is no pro-rata calculation for LTFT trainees. You need the same quality and breadth of evidence as a full-time trainee — it may simply take longer to accumulate it given your working pattern.
Can I do COTs or audio COTs during an OOH shift?
Yes — and it's encouraged. WPBAs in the OOH setting are valuable and broaden your portfolio evidence. However, this is only possible if your Clinical Supervisor is trained in WPBA tools. Check before the session, not during.
My OOH session was quiet and nothing happened. Does it still count?
It depends entirely on what you did with the quiet time. A session where you discussed OOH organisation, ethics, governance, or clinical topics with your CS can produce excellent capability evidence. A session where you sat doing nothing and wrote a one-line entry produces no capability evidence and will need to be repeated. Make every session count — ask your CS to engage with you. Don't leave a quiet session without a meaningful discussion.
Can I do OOH during a hospital post?
No. OOH work for GP training purposes can only be done during GP placements. In hospital posts, you should be engaged in your department's own on-call rota programme.
Can I do OOH whilst on maternity leave, OOP, or sick leave?
Absolutely not. Your indemnity is very unlikely to be valid during these periods. This is non-negotiable.
What if I haven't done enough sessions before my ARCP?
Be honest with your Educational Supervisor as early as possible — not two weeks before the ARCP. If you're going to be referred, it's much better to have a plan in place than to arrive without one. Your ES and TPDs can advise you on the fastest way to build sufficient evidence. And remember — the earlier in your training this is identified, the easier it is to address.
Why do I have to do OOH if I don't plan to do any after qualification?
Because the skills are inseparable from being a safe GP. Every GP does on-call. Every GP triages urgent calls. The capabilities you build in OOH — working with limited information, making decisions in uncertainty, communicating safely under pressure — are used every day in routine GP practice. And plans change. The GP who said they'd never do OOH at the end of ST3 sometimes finds themselves working rurally three years later.
West Yorkshire Smartcard — How do I get access for OOH?
💳 West Yorkshire Smartcard Access
West Yorkshire now uses a Microsoft online form for smartcard access — replacing the old downloadable paper version. This makes the process faster and easier.
→ Complete the smartcard access form here
⚠️ Allow up to 2 weeks for processing. Do this well before your first OOH session.
The things to carry with you from today. These are the bits that matter when it's 2am and you're not sure what to do.
OOH is the part of training that most trainees dread before they start — and most trainees reflect on fondly once they've qualified. The resilience, clinical confidence, and consultation skills you build in those late-night and early-morning sessions are real. They follow you into every subsequent consultation you ever have. Do it well. Reflect on it properly. And above all — use it to become the doctor your future patients deserve.