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Exception reporting guide for senior doctors

The new 2016 terms and conditions of service for doctors and dentists in training have now been introduced. This includes a new system for monitoring junior doctors’ working hours and ensuring they work safely.

Junior doctors will now have a work schedule, which will set out their rota template and the training opportunities they must have in their placement. When their actual work varies significantly or regularly from this schedule, they should file an exception report to indicate that something has gone wrong.

Exception reports will be sent to the trainee’s educational supervisor, and copied to the guardian of safe working hours. Often the educational supervisor will be a consultant or other senior doctor, so if you currently take on this role, it is important that you understand what exception reporting is for. This way you can support your junior colleagues as they start work under the new terms and conditions.

This extension of the educational supervisor’s role will also have implications for their workload, and it is important that they are supported in this transition. The 0.25 PA commonly allocated for this role per trainee may need to be varied locally, and the non-educational element of the changes will be a new skill for many.

 

Executive summary

  • Exception reporting is a feature of the 2016 contract which allows junior doctors to immediately report instances where their actual work and training opportunities vary significantly and/or regularly from their work schedule. The report is sent to educational supervisors as well as guardians of safe working (for work issues) or the Director of Medical Education (for training issues).
  • Effective exception reporting should result in timely adjustments to trainees’ work schedules, and, where appropriate, allow trainees to receive additional pay or time off in lieu.
  • Trusts commonly allocate 0.25 PAs per trainee to educational supervisors.
  • Exception reports can cover a wide range of issues, including extra hours outside of their work schedule, not meeting training needs, not receiving breaks, working more hours during an on-call period than is in their prospective estimate, and many more.
  • Educational supervisors will review exception reports and then discuss them with the trainee to agree what action is necessary to address the issue. This could involve revising their work schedule, and approving claims for additional pay or time off in lieu.
  • If a solution agreeable to both parties cannot be found, this needs to be raised with the guardian of safe working.
  • Senior doctors can support their junior colleagues by creating a culture of honesty and encouraging them to exception report. In the long term, this can and should mean that wider problems, such as understaffing, which are out of both junior and senior doctors’ control, can be raised with trust management and resolved to everyone’s benefit.

 

FAQ for senior doctors

  • What is exception reporting?

    What is it for?

    It allows trainees to address issues regarding hours worked, breaks not taken, or training opportunities missed as they arise, and make timely adjustments to their working patterns where needed, as well as getting sign off for either time off in lieu, or additional pay if they have been required to work beyond their scheduled hours. This function does not exist in the current contract, so it only applies to trainees working under the new 2016 terms and conditions.

    Significant numbers of trainees will remain on the 2002 TCS for some time during a phased transition, and all trainees in the devolved nations plus any on long-term lead employer contracts will stay on the 2002 TCS indefinitely and cannot use exception reporting. Trusts will need to maintain, and LNCs continue to supervise, the current diary reporting system for these doctors.

    What is the benefit?

    Exception reporting allows for immediate action to be taken to change the trainee’s work schedule if it isn't fit for purpose - for example, by including the extra time they need to stay every night in the rota and adjusting their salary accordingly. It also allows for trainees to receive additional payment or time off in lieu, depending on the circumstances.

    Trainees don't have to suffer on a bad rota for a whole placement, with only the possibility of some back pay months down the line - they can sort problems out quickly, getting rest when they’re too tired, pay when they’re overworked, and changes to their work schedule to make sure it doesn't happen again.

    The data on the number of exception reports filed in the trust per grade, specialty, and so on, will be included in the guardian of safe working hours’ regular reports to the board and the LNC, so it is a positive way to quantify staffing issues at the trust. The system is a good opportunity both for junior doctors and their colleagues to identify problems quickly and get them resolved.

    What is a work schedule review?

    If shift overruns are frequent and persistent, it may be necessary to undertake a work schedule review, change a trainee’s schedule to make the overrun part of their planned hours, and adjust their salary going forward accordingly.

    This is a conversation between you and the trainee about whether the work schedule is fit for purpose, which may prompt one or more of the following outcomes:

    • No change to the work schedule is required, but compensation in the form of pay or time off in lieu is required for one or more individual breaches of the work schedule.
    • Prospective changes are made to the work schedule so that going forward from the review, the trainee’s hours and/or training commitments are changed with a corresponding adjustment of their pay.
    • Organisational changes are needed, such as a review of the timing of ward rounds, handovers and clinics.
    • If such organisational changes are needed, this may take a while to happen. In the meantime, temporary alternative arrangements should be made where necessary, such as an amendment to their pay.

    The outcome of the review must be communicated in writing to the trainee. If they are not happy with the outcome, there is a process in place for them to follow this up.

    The process is outlined in detail in schedule 5 of the contract, and it provides for ultimate escalation to a final stage work review, which is a formal hearing under the employer’s local grievance procedure with a trade union representative on the panel.

  • What are the logistics?

    How will it work?

    The contract specifies that there must be an electronic system for exception reporting provided by each employer. This is likely to be an app, and at a minimum should be via email - so no time-consuming paper forms that have to be handed in at a certain place. When you discuss an exception report with a trainee, whatever outcome is agreed must be communicated with them in writing in an electronic format afterwards.

    What exceptions can be reported?

    Trainees can exception report virtually anything – it is a quick and easy way of flagging that something is wrong. This could be because:

    • they have had to work extra hours
    • they are not meeting their training needs
    • they haven't been able to take breaks
    • they ended up doing more hours of work during an on-call period than is in their prospective estimate
    • and much more.

    All exception reports are sent to the educational supervisor and copied to the guardian of safe working (or the Director for Medical Education if it is an issue with training), who needs to ensure the problem is dealt with in a timely way, acting as an independent arbitrator in any disagreements between the trainee and their supervisor.

    Exception reporting may also be appropriate for academic trainees (such as Academic Clinical Fellows) in circumstances where increased demand in their clinical work detracts from their protected academic time, even if the total hours worked do not go beyond the work schedule. In such cases, the trainee should be able to exception report this to their academic supervisor, copying in their clinical supervisor or another representative of their NHS employer.

    It would then be for both employers to consider how the issue can best be addressed, including a review and restructuring of the work schedule. If trainees feel pressured or bullied into not filing an exception report by any of their colleagues or their supervisor, they are encouraged to raise this with the guardian, with the LNC, and through the trust bullying and harassment policy.

    What do I do if I receive an exception report?

    Exception reports will be sent to you and copied to the local guardian (or the DME if the issue relates to training). You would review the content and then discuss it with the trainee to agree what action is necessary to address the issue. We suggest that you start recording the time this takes each week as soon as you receive your first exception report, for discussion at job planning.

    This could mean sitting down with the trainee in a work schedule review to revise their work schedule if you think this is where the problem has arisen from, or by approving claims for time off in lieu or pay as appropriate.

    You would then set out the agreed outcome of the exception report, including any agreed actions, in an electronic response to the doctor (and copied to either the DME or guardian of safe working, depending on whether the issue is educational or safety related, or both).

    Will trainees get paid for extra hours?

    The new TCS allows for exception reporting to be used as a mechanism to claim compensation when trainees are required to work longer hours than planned. If trainees are required to work beyond the hours scheduled in their work schedule they should therefore be compensated for this, as junior doctors should be supported to work within safe limits and not expected to do unpaid overtime.

    If a trainee wishes to claim pay when they are required to do extra work, they should submit the exception report within 7 days. Ultimately any claim for pay needs to be authorised by their manager; in practice, this is whichever person would be in a position to verify that they were required to work extra time for the needs of the service. It is useful if their manager can authorise the pay in advance by confirming in writing that they are being required to do extra work, and that they should therefore be paid. It isn’t essential however, and the contract states clearly that authorisation can be given afterwards by filing an exception report.

    If a junior doctor is exception reporting a breach of their work schedule that also constitutes a breach of the maximum safe working limits (maximum 48 hours average working week, maximum 72 hours worked in 7 consecutive days, rest between shifts reduced to less than 8 hours, breaks missed on 25% of occasions across a 4 week reference period), then they can be paid at an enhanced rate as a financial penalty to the trust.

    The guardian levies a fine of four times the hourly rate, some of which goes to the doctor to pay for the additional hours at one and a half times the locum rate, and the rest goes in a pot of money to be spent on educational opportunities for juniors at the trust.

    If an extension of a trainee’s working hours threatens to take them over the upper safe working hour limits, then time off in lieu may be the best option, but you should discuss this with the trainee following their exception report. If they have breached the rest requirements and need to take time off in lieu, this must be taken within 24 hours unless they declare themselves safe for work and their manager agrees, in which case it can be accrued if they prefer.

    Time off in lieu as a result of breaches of hours limits, rather than rest requirements, can be accrued or ‘banked’ for up to three months. Where time off in lieu can’t be taken within the relevant time limit, the trainee should be paid. You should state clearly the details of any time off in lieu a trainee is going to take in the electronic written communication you send them following your discussion of their exception report. You should agree with the trainee a time and date for the time off to be taken, and not leave it up to the trainee to find the time.

    The written outcome should also be clear about the timeframe within which the time off must be taken, and clarify that payment will be made if the time off can’t be taken.

  • What am I responsible for?

    What are my responsibilities as a supervisor?

    In the definitions section of the TCS, the term educational supervisor extends to cover approved clinical supervisors in GP practice placements, who will be responsible for the management of exception reports in these settings. Although the educational supervisor retains overall accountability, it may be appropriate that exception reports are also copied (or sent instead) to other appropriate persons for action - for example, the doctor’s clinical supervisor.

    Ideally you will be able to find a solution with your trainee to the underlying reason for the exception report. However, this may not always be possible due to recruitment issues and rota gaps - you are not accountable for this. If you and the trainee cannot find a solution, then it is the responsibility of the employing organisation to find a solution. We suggest you raise this with the guardian urgently and repeatedly if necessary.

    If no guardian is in place, the Trust is in breach of contract. In this instance please contact the BMA and notify your Local Negotiating Committee.

    Some doctors, especially foundation doctors, may not have an educational supervisor based at the location where they are working. In this case, the formal responsibility for the exception reporting process may be re-assigned to the doctor’s clinical supervisor.

    This should be agreed in accordance with local negotiating policy, and with consent from the junior doctors affected. Any such arrangement should be explained to junior doctors in advance, and the overall accountability in contract terms still rests with the educational supervisor.

    What if I don’t have enough time to take on this additional work?

    You need to speak to your employer about any changes that may need to be made in order to ensure you have sufficient time to take on these responsibilities, which are critical in the new junior doctors’ contract.

    It is a contractual requirement for junior doctors to have access to an exception reporting system with timely responses, and it is the employer’s responsibility to ensure this can be delivered. Even if you do not wish to record a comprehensive job plan diary, it will be very useful for you in subsequent job plan discussions if you record how much extra time this takes each week.

    If you decide that the role of Educational Supervisor is no longer for you, you are entitled to request a job plan meeting at any stage. The BMA can support you with this, but remember: you may lose the 0.25 PA per trainee that is commonly included.

    How can I approve claims for additional pay if my employer tells me the trust cannot afford this?

    There are clear contractual provisions in the 2016 TCS allowing junior doctors to receive additional pay for extra work they have been required to do. If it is found that a legitimate claim for additional pay has not been approved due to financial concerns, the trainee will be able to ask the independent guardian to step in and take action to address this.

    All junior doctors working under the TCS have the right to access all the contractual protections and benefits it provides, and if trusts are choosing of their own accord to introduce this contract, they must ensure they have sufficient funding to resource it.

    If you experience pressure or bullying from your employer when it comes to approving claims for pay or time off in lieu, you should notify the guardian of this, and if necessary contact the BMA for support.

    Will I be blamed if the trainees I supervise are frequently exception reporting?

    No, you should not be, and you should contact your guardian of safe working hours and the BMA if you experience this. Trainees should be encouraged to exception report as part of a wider culture of openness about problems at work in order to promote patient safety.

    The point of exception reporting is not to apportion blame, but to acknowledge problems that arise, and work together to deal with them quickly. It is not ultimately your responsibility to find a solution - it is your employer’s, and it is far more important that you understand the problem that your trainee is sharing with you, and do your best to help as far as possible.

    This could even mean the realisation that existing ways of working that may not seem problematic and just ‘the way things are’ actually contravene the new rules in the contract and should be changed.

    If, for example, a junior doctor is required to arrive at work an hour earlier than scheduled each day in order to prepare for the start of work, this may be standard procedure, but it would merit an exception report as it goes against their work schedule. Similarly, if a trainee is told they are free to leave on time but that they ought to stay in order to benefit from a training opportunity, this too would merit an exception report.

    Consultants and other senior doctors can support their junior colleagues by creating a culture of honesty and encouraging them to exception report, but only if they themselves feel supported. In the long term, this can and should mean that wider problems such as understaffing, which are out of both junior and senior doctors’ control, can be raised with trust management and resolved to everyone’s benefit.