A. Getting started on your own where no scheme exists

1. Get “buy in” locally from your supervisor and/or GP practice You need support from your educational supervisors to supervise clinics and allow you the time to do them. Clinics are usually a timetabled activity for the GP registrars. Paediatric registrars need to get agreement of release form their other activities. Some places may “rota” the clinics in, others ask you to book time out as study leave. This will have to be discussed individually.Ensure that everyone understands the Governance arrangements – essentially clinical responsibility remains within primary care, with the GP trainer, hence the need for tight supervision and presence by GP trainer on the day.

2. Identify a pair/partner – this can be done in a variety of ways
   It may be that you know/have regular contact with someone from your area and can get started like that. Otherwise, for GP trainees you could approach your local Paediatric department – Clinical Lead or College Tutor –  and ask if anyone is interested. For Paediatric trainees seeking GP trainees, either do so through local contacts or through the VTS leads in your area.

3. Meet up with your pair and set some dates for clinics
   Ideally the clinic should be on a day when there is a practice meeting or forum at lunchtime for the pair to feedback to the rest of the practice about the patients seen enabling clinical continuity and cascading of learning. Plan to include practice nurse/HV if possible in team discussion.GP and paediatric registrars choose clinic dates to suit the GP trainee/practice and Paediatric trainee release from the trust rota. Start with two or three dates that are booked at the practice and give the practice enough lead-in time to book children and young people in.It is also a good idea to share what you hope to get out of clinics – what your learning aims are – is it to manage common conditions such as constipation, or identify sick children etc. You can book children in accordingly.

4. Advertise clinics amongst GP staff
   GP registrar advertises the clinic to rest of GP staff. S/He explains the rationale, which patients to book in, how the clinic runs etc.  It is important to note that although there should be a couple of acute/unfiltered primary care appointments each clinic, if there are too many (i.e. the appointments are not filtered by medical staff) there is much less learning.

Starting a whole scheme locally is a bit different.  It needs support (and commitment) from both a Paediatric and GP training lead, who then do this process for a whole area. This can still be led by trainees. Emails for expressions of interest can be sent to trainees in the patch. The rate-limiting step is often the availability of Paediatric trainees in an area, or how many trainees can be released form Paediatric rotas. It may be that GPs without Paediatrics experience are prioritised if there are more GPs keen to take part. The trainees then need to be paired up according to the days they are available – see registration sheet.  Once you have been paired up, pairs should be encouraged to meet up and set dates – as in 3. above.

B. Running clinics – practical aspects

Booking in children and young people – who how and where?

Patients booked by practice staff – triaged by the participating GP registrar. We suggest:

• Six 20-30 minute slots
• Two 10-15 minute “walk in/emergency slots” booked on the day

Patients who could be seen in the clinic:

• Routine follow up, or annual review of common childhood illnesses, asthma, idiopathic constipation, eczema, allergy etc.
• Child with problem X who has seen before in primary care but is difficult to manage
• Frequent flyers in the last six months to GP or urgent care
• Children discharged from secondary care and in need of follow up
• Children who might need referral to general paediatrics outpatients
• Two walk-ins to demonstrate ‘usual’ unfiltered GP care.

Patients who shouldn’t be referred to the clinic:

• Children in need of specialist paediatric input, eg: diabetes, neurology
• Emergency referrals – red flags – seen by other professionals in the practice should not be delayed by being booked into this clinic (unless they are a walk-in appointment).

Clinic preparation – a few days before

• Participating GP registrar emails paediatric registrar with patients booked (problems not names) 1-2 days before to allow preparation
• Remind the practice about the feedback meeting happening at the end of the clinic (if applicable)

Clinic day: example

• 8.30am: Pre-clinic discussion around patients to be seen
• 9am -12 noon Six booked slots
• 12-12.30pm Two emergency slots – to see unfiltered primary care
• 12:30-1pm Debrief/discussion with GP trainer/filling in learning log etc.
• 1-1.30pm Feedback of patients at practice meeting and virtual MDT
• Paediatric trainee returns to hospital/Community and discusses patients with paediatric supervisor

It may be that the discussions with the GP trainer happens in the practice meeting.

After clinic – Ongoing email/telephone contact between GP and paediatric registrars about patient management and follow up.

Governance

These are training clinics within Primary Care. Clinical responsibility remains within primary care, with the GP trainer, hence the need for tight supervision and presence by GP trainer on the day. If the GP trainer is not present, they need to identify a nominated deputy to debrief or be present at the debrief meeting on their behalf.

A formal governance agreement exists for clinics taking place within London, agreed by GP and Paediatric training leads. This should be signed by those taking part. It can also be adapted for use in other areas.

Because of these arrangements  the Paediatric trainee does not need further contracts/Honorary contracts with the GP practice. They are covered by their Hospital Trust in the same way that Foundation doctors are in Primary Care posts.

D. Supervision and learning

Supervision should be on-site from the GP supervisor – they should debrief with you immediately after clinics – ideally in a wider practice meeting. Debrief/supervision from the Paediatric Supervisor can happen remotely or at some point in the next few days.

 Maximising learning from clinics and top tips

Our evaluation has shown that maximum learning come from at least 4-6 clinics done by a single pair, as their relationship develops over time, although in some sites there have been rotating registrars to allow for more people to do clinics. They also report valuable learning.

Getting advance warning, a “heads up” of the patients booked in allows time to prepare/look at guidelines etc. This means that both trainees have already done some pre-work.

Feedback to the wider group of the GP practice is not only important for patient care, but allows cascading of learning. It also means that some of the wider principles can be drawn out and shared. These discussions can also include management of other children who haven’t come to clinic – a virtual MDT. Some trainees use them to do micro-teaches on particular topics too.

The final part of the intervention – the discussion with the Paediatric supervisor – is an equally important part of the intervention – both in the patient pathway and for further learning.

Trainees are encouraged to fill in a learning log of what they have seen and learnt that day. This can be done together at the end of clinic, or separately. This encourages reflection and also can be shared with others. For example, if the registrar pair fill in the log together at the end of the clinic, it can be circulated to the wider practice team but also to the Paediatric Consultant supervisor who can then have an overview of what has been seen to aid in their debrief discussion with the Paediatric trainee. It also forms a really good basis for WBPA/case based discussions.

Reflective workshops

For the pilot programmes, we have been running reflective workshops to bring the pairs together and get them to reflect and share their learning. This also gets the trainees working together, and enables troubleshooting around clinic organisation.

A sample workshop timetable can be found here (hyperlink).