For junior doctors

Exception reporting and monitoring

Exception reporting was introduced to the junior doctor contract in 2016 in England as a means to flag concerns in real time.

Exception reporting creates a log of the impact of understaffing and doing it can help bring about lasting improvements through rota change and other changes.

You are contractually entitled to exception report any deviation to your agreed work schedule - including overtime and staying late, being unable to take contractual rest breaks, and missing educational or training opportunities. Understaffing is a valid reason in itself to feel unsafe on shift. If you feel that your work environment has insufficient doctors or senior decision maker support, and that this is affecting your ability to deliver safe care, please consider using exception reporting to escalate this.

Training on the local exception reporting technology must be provided by your employer and should take place during working hours. You can watch tutorial videos which show how to submit an exception report on Allocate, DRS4, and HealthRota.

• Guidance on exception reporting

In Northern Ireland, Scotland and Wales

While exception reporting is not part of the junior doctor contract in other parts of the UK, you should undertake monitoring of your working hours if you are working in Northern Ireland, Scotland and Wales.

Accurate monitoring of your hours and working patterns by your employer is compulsory and should take place twice a year for two weeks. You may wish to request rota monitoring at any other time if you feel that your rota doesn't reflect the hours you work.

• BMA recommendations for ensuring effective monitoring

Checking your rota

Short staffing means rota gaps are a persistent problem. This adds pressure and intensity of workload to junior doctors in post, who are often implicitly expected to cover gaps.

You can protect yourself by staying alert to potential changes in your rota patterns or duties on rotation change-over dates. Any change must occur in accordance with your contract (Terms and Conditions of Service), the guidance issued by the relevant Government department, and requires the agreement and involvement of junior doctors locally.

The BMA junior doctor committee has produced guidance on what your employer can and cannot ask you to do within the terms of your employment, which covers emergencies, short term and long term cover, as well as potential implications on training, pay and what to do if you are being forced into working extra hours.

The BMA's good rostering guide, which was developed in agreement between the BMA and NHS Employers, includes the below checklist.

The guide was developed in relation to the 2016 contract for trainee doctors currently in use in England, but its principles apply when rostering all types of doctor in any of the four UK nations.

Your rota checklist

When you have received your rota, you are encouraged to ask yourself:

• Did you receive this with sufficient notice as defined by the Code of Practice in your nation?
• Have you been given a copy of your employer's policy or equivalent document stating the requirements of the roster manager and doctors working under the roster that has been agreed by your LNC (Local Negotiating Committee)?
• Have you run your rota through the BMA's rota checker tool (England only), and is it compliant with the rules?
• Were you consulted on the design of this rota? If not do you know which doctors were involved, and how to contact them with any questions?
• If this is a change to an existing rota, have you been given 6 weeks' notice?
• If you're LTFT (Less Than Full Time), has this rota taken into account any set working days you have?
• Is the rota as a whole balanced, with different types of shifts (on-calls, nights, long shifts) evenly distributed?
• Is there enough time for handover and admin work in the shifts you're rostered for?
• If there is NROC (non-resident on-call) in the rota, does the pattern accurately reflect the intensity of work you'd expect, and is NROC definitely appropriate here rather than a full shift?
• Is it possible for you to take annual leave when you need to rather than leave being fixed in the rota?
• Are all your training needs able to be met in this rota as it currently stands?
• Is there a straightforward process for swapping shifts if you need to?

If the answer to any of these questions is 'no' contact your Educational Supervisor - or your manager, if your Educational Supervisor is not the best person to contact - and refer them to the jointly agreed good rostering guidance.

NHS Employers’ Rota Rules at a Glance factsheet lists the new rota rules for junior doctors as outlined in the terms and conditions of service under the 2016 contract for trainee doctors currently in use in England, and may be another helpful resource for use when checking your rota.

For consultants

Maintaining safe services

As a consultant you have a responsibility to monitor the safe working of the wider clinical team and to be available and approachable so that colleagues feel able to raise safety concerns.

During each shift, you should:

• Know whether you have a full complement of members and know who those team members are.
• Be able to make an informed judgement about whether the team is able to deliver the care expected of them.
• Be informed of changes to anticipated workload and be able to match the available resources to the expected clinical demand.
• Have adequate job planned time for handover.

You also have a responsibility to ensure that concerns are listened to, documented properly, and taken seriously.

Use the following key principles when recording concerns:

• Consider carefully the correct tool or mechanism to record or raise a concern.
• Contextualise critical content by carefully recording systems pressures and contributory factors.
• Re-read all content and ensure that it could be read without ambiguity or inappropriate blame by a third party. Ensure that it is factually accurate.
• Record the name and role title of the managerial personnel you have spoken to. It may be that some of these conversations will need to be repeated or held with other managerial personnel. Such conversations may require witnesses, especially if there is resistance to following the advice of the consultant. Incident reporting should be undertaken, and formal concerns raised in writing, where necessary.
• Follow up face-to-face or phone conversations with emails detailing what you have discussed, copying in the trust medical director and senior on call trust director, to ensure that you have established a record of events while the details are still recent.

Steps to take if a service is unsafe

1. Raise your safety concerns with the duty manager and document this via an incident reporting system such as Datix or equivalent.
2. Put in place any mitigation that you can reasonably undertake within the resources and authority that you have. Inform the duty manager and document that action.
3. Inform the duty manager if mitigations are unlikely to be sufficient and seek urgent support for more sustainable solutions.
4. If there has been no resolution, contact the next most senior clinical manager available.
   
   a. Where concerns persist and/or support has been inadequate, escalate concerns (referencing actions taken) to the duty Medical Director. Document the action.
   
   b. Where immediate support through the management structure does not address the concerns, explain that you are continuing to provide care to the best of your ability under circumstances that your employer has failed to address, despite your interventions, and the employer will carry appropriate responsibility should there be adverse events or outcomes. Document the action in your incident reporting system.
   
   c. Follow up your earlier actions in writing to your Medical Director. Focus your email/letter on fact, being accurate and informative, referencing actions taken and appropriate advice, so that your key message is not lost.
5. Consider contacting your MDO (medical defence organisation) for advice.
6. Consider the options open to you to raise your concerns via your employing organisation’s whistleblowing mechanisms or via your employing authority’s Freedom to Speak Up Guardian or equivalent where these are in place.
7. Where you have taken all appropriate escalation and intervention actions yet concerns persist and/or support has been inadequate, consider informing the Chair of the Board and/or non-executive directors of your safety concerns, and:
   
   a. consider involving your LNC officers as part of this
   
   b. involve your MDO
   
   c. be specific, factual and accurate, with as much appropriate information as possible
   
   d. consider informing the GMC) of your concerns on the next working day and, if you do so, document your interaction.

In the acute situation it may be difficult to undertake a number of these steps whilst still providing care. It is advisable for senior doctors to consider the possible options to mitigate problems in advance, as a team, and preferably with an action plan for such events.

For more information, see the BMA's guidance for consultants working in a system under pressure.

For SAS doctors

• Short staffing means rota gaps are a persistent problem. This adds pressure and intensity to the already heavy workload to SAS doctors. You can protect yourself by staying alert to potential changes in your rota patterns and by knowing your rights: please see the ‘Checking your rota’ section of this document (under ‘For Junior doctors’) as much of this will apply to you too.
• As SAS doctors you may not have access to exception reporting. In addition, SAS doctors continue to report experiences of bullying and harassment and difficulties with receiving adequate support for their health and wellbeing. The new strategic ‘SAS Advocate’ role has been developed in order to promote and improve for support for SAS doctors’ health and wellbeing. Please see the joint guidance from the BMA and NHS Employers for more information on this role.
• Contractually, you should have at least one PA (Programmed Activity - a total of four hours) per week of SPA time under the 2021 specialty doctor and specialist contracts. Any SPA activity such as teaching, research, clinical management or medical education roles would call for additional SPA time. You should have access to appropriate opportunities for personal development and your employer must consider these as part of your job plan review. You can use the BMA’s SPA time guidance for SAS doctors to make sure you know what you are entitled to.
• When asked to leave your Supporting Professional Activities (SPA) for another clinical activity, make a record of this to ensure the time is given back to you at another time.
• If you are ‘acting up’, this should be in accordance with the terms and conditions of service in your country.
• You should ensure that your job plan clearly documents what work is required to be delivered by you.
• For other responsibilities that may apply to you, please see the ‘For Consultants’ section of this toolkit.