Bring on exception reporting - our collective mechanism to record and report data on the realities of our working lives. Statements about working over hours or while under-staffed will no longer be anecdotal but rooted in hard evidence.
The idea of exception reporting is to raise any instance where your actual work varies from what you are scheduled, and paid, to do – both one-off situations and also incidents where your working life is adversely affected by a systemic problem. This may include continued under-staffing on a ward, staying at work consistently after hours or finding that the design of a rota is unworkable in practice.
The format of exception reporting will vary from hospital to hospital but it must be an electronic system, ideally an app or a simple online form, but an email at a minimum. The idea is that the problem identified will ideally be solved at a departmental level, but there is the potential to escalate an issue – from the individual doctor to a clinical/educational supervisor, to the guardian of safe working, and then through the tiers of management.
Over the past month, at a teaching hospital in East London, we have been piloting the exception reporting process. Here are some thoughts of how to get the best out of the process.
1 Build and communicate a positive culture around exception reporting
Tell your colleagues, consultants and hospital managers that you will be exception reporting from the start of being on the new contract, and that this will be expected of you.
Clearly, it’s important to know who your guardian of safe working is, and that they have taken every step to inform and update clinical staff about what exception reporting involves, and what it’s for.
Everyone needs to know that this is a system to gather data, and proactively to highlight and help solve the system problems that exist in the NHS. That’s what makes it such an important mechanism. It’s not about attacking individual hospitals, still less individual members of staff.
2 Be brave
Until exception reporting is seen as a positive tool to improve the way the NHS is run, you are likely to meet some resistance, especially from the people to whom you report. A good strategy is to inform your supervisor or head of department about the exception reporting process - and stress that this is a collaborative mechanism to improve working practices.
Don’t be put off by one bad experience. As one of my colleagues put it, it’s better to have a process like this than a post left unfilled in the long run because of the working conditions associated with it.
3 Learn how to do it, and show others
Have the link for reporting easily available. An app or a national online platform may be developed in future – if it is, and you think it would be a good option for your trust, advocate for its use.
4 Be pragmatic
Exception reporting applies where you have to start earlier or stay long after your finish times regularly, because the staffing is inadequate or poorly planned, that this becomes an issue. In my view we have a responsibility to raise such issues specifically and this tool gives us the means to do that.
For the system to work at its best, explain the details around the incident you are reporting. This was the feedback from the consultants in our trusts who were dealing with the reports. Simply saying that we finished late was less useful than detailing why we finished late, and whether there had been any breaks in the day.
And while reports should be timely, it may not be efficient for you or your employer to, for example, submit one every day if you have a run of late stays. At our hospital we compiled such reports on a weekly basis – but remember that if you are making a claim for pay, it needs to be submitted within seven days of the exception to your work schedule.
5 Feed the information up the chain
Make sure that the content of your reports reaches leaders with influence. An active way to engage in this is to join your trust’s junior doctor forum. This is a new forum to enable trainees across all disciplines to meet the guardian of safe working to discuss and escalate problems identified from exception reports and other means.
Joining this forum can help you shape the quarterly report which analyses junior doctors’ experiences in the trust and goes to senior management. On a national level we may also push to coordinate these reports between hospitals and feed them even further up the chain of management.
6 Keep on going
This is our opportunity to build a bank of data which captures the on the ground working in the NHS which can be fed which will be fed back to management and government.
It is a turbulent time for junior doctors. Many of us, including myself, believe that the way the NHS is currently resourced and managed will have a negative impact on patients, and it is particularly pertinent to note this following the release of the Chancellor’s autumn statement, which allocated no additional funding to the NHS.
However we can’t give up. Our reaction should be to do what as scientists we’re good at – measure, analyse and report data and let evidence correct the current management of the NHS to best practice.
Martha Martin is an F1 doctor in east London
Read the BMA guidance on exception reporting
The best way to make the most of exception reporting is to exception report each and every time our daily work differs significantly from our personalised work schedules in either working hours or working content. Exception reporting: no exceptions.
A requirement to cover for colleagues on an ad hoc basis for short term gaps due to sickness or personal emergencies is an expectation in all professions, however medicine is dismally prepared for this. I disagree that doctors should be pragmatic in highlighting this issue as employers can not plan adequately for absence if they are not aware of the impact this is having on others. Exception reporting each variation from our work schedule ensures the information collated is an accurate reflection of our working lives and encourages colleagues to be open about any difficulties faced without fear of being singled out. It has been highlighted that some trainees may work beyond their hours when their workload should be achievable within the hours set in the work schedule- in these circumstances exception reporting should be seen as a positive tool to highlight those who may need additional support and/or guidance before a problem escalates.
By creating a culture where exception reporting is seen as the norm, resistance to the process and fear of submitting these reports should diminish over time.
I think we should be reporting covering for people being off sick/study leave/annual leave. anything that leaves the rota short is a patient safety issue. In Australia and new zealand they have 'leave relief' placements, that everyone takes it in turns to do.. so vacancies - sick or otherwise, even short term, are covered. In my year there, it was extremely rare not to have a full quota of Dr's on shift. In ED they had an added buffer of people being '2nd on call' where u could be called in to cover.
In new Zealand if u cover someone's work who is on sick you get paid extra.
There are ways round sick leave.
I suggest one correction. "Don’t report one-off situations unless there seems to be a genuine problem. People being off sick for a day or two meaning you have to cover their work is a reality in any job." - this is wrong. I have read the new Terms and Conditions. We should be exception-reporting every incident (except perhaps those times when we stay late but have already been authorised to do so in advance or during the period of late working).
For example, imagine that ENT have an SHO and an SpR every night. One weekend night, the SHO is ill. This means the day SHO has to stay 3 hours late to avoid the service collapsing, and then has to come back in the next morning after just a few hours sleep. This is not safe. This situation is not 'a reality in any job' - as the other comments show, adequately-funded health systems have sufficient reserves built into the system that they cope comfortable with normal levels of sickness.
If we exception-report every incident, trusts will soon find that it is cheaper to have better staffing levels than it is to operate at the margin of safety as most of them do now.
"If we exception-report every incident, trusts will soon find that it is cheaper to have better staffing levels than it is to operate at the margin of safety as most of them do now."
Do you really think trusts will care that much?
Exception reporting is an individual process and will be easier to ignore/appease/fob you off. And that's if you report; because many won't
The trust fining themselves isn't that much of a punishment. If you're persistent they'll probably just give you some time off in lieu and be done with it.
The process is flawed. However, it's all we've got so I'd encourage everyone to 'be brave' and report as much as possible!
We have already had one trainee reprimanded for putting in exception reports - and told that this behaviour is unprofessional. I expect this is going to be replicated across hospitals around the country. People will not be using this system as the report goes to senior clinicians and not straight to managers. Clinical supervisors should be keep out of it completely. this system will be used in a select few hospitals and for the rest will become obsolete similar to diary carding..
Hi All, this is Martha here the author of the blog.
Thank you for such interesting comments and discussion. To respond to some of the points raised:
- Firstly the point on reporting any discrepancies from your work schedule which occur, including when they occur from colleagues being away. Several people have raised this point from different aspects. On reflection, I agree with the necessity of documenting all of these these occurrences to more acurately reflect what is going on on the ground.
- It was an interesting to point raised that our healthcare system could be better at being prepared for occasions of short staffing and it would be more cost efficient not to operate at "the margin of safety." Perhaps we could brainstorm further ways to combatt this? The Australian and New Zealand examples of "leave relief", "2nd on call", and being paid more for covering the work of someone who is off sick are all models we could learn from and apply here.
- The comment "The process is a flawed" - I agree with this. And the comment below which sites someone being reprimanded for Exception Reporting does not surprise me. However, the accusation of the trainee acting as "unprofessional" is the absolute opposite of fact. In these occasions where we are met with an old culture of working I do believe we need to be brave and keep on going. Only by standing up for our employee rights will anything change.
I suggest that we also brainstorm how to improve the Exception Reporting process here. We need to make this work for us.
Dr Eleanor Wood, Director of Medical Education, Homerton University Hospital, London.
Many thanks for this interesting article, though I have serious disagreements with point 4. I am glad you have reflected on your original opinion and subsequently changed it.
I would like if I may to take you back one calendar year to the SJT, one of the answer rationales is as follows - "It should not be necessary for anyone to work for longer than their required hours because of what is essentially an organisational problem, not a medical emergency"
As has already been mentioned in other professions it may be reasonable to cover for an unwell colleague, however in medicine the stakes are much higher than in say a law or an engineering firm, and patient safety is our first concern. Therefore adequate cover should be provided for staff sickness for the trusts not to do this is unacceptable and if cover is not adequately provided then it should be exception reported, end of.
This is worrying from the BMA, why are we being told not to exception report anything, unless we stand firm on small bridges Trusts will continue to abuse us, we have to collectively show zero tolerance to work outside our schedules which means exception reports for everything. It beggars belief that the BMA have published this.
Well done Dr Martin on taking the initiative that should have come from more senior BMA 'leadership'.
However, as many have already mentioned below, unfortunately there are many flaws with the way you have interpreted the exception reporting process, which is not a criticism on your work. But for the BMA to use it as official guidance I find absolutely horrifying.
The trainee-supervisor relationship can be very fulfilling and supportive, but can also be fraught with concerns. Ultimately supervisors have significant power over trainees as they have control over their future career prospects. This becomes an increasing reality as one ascends the training ladder, which is partly why it is so concerning for an FY1's work (excellent it may be) to be used as official guidance from the BMA.
There is a huge variation in the way consultants / supervisors interpret the contract dispute, junior doctors training in general, and therefore also the specific issue of exception reporting. Trainees are concerned to accurately exception report, because Trusts apply pressure to supervisors, who in turn apply pressure to trainees. There is absolutely no anonymity and to 'be brave' is a lot easier said than done, especially when morale among trainees is so much at rock-bottom that many just want to keep their head down and end the terrible training conditions by means of CCT.
Exception reporting was designed to gather data to show people (the public, GMC, government, etc.) just how much junior doctors go the extra mile out of goodwill, and how that goodwill is abused by employers en-masse. Employers are given a choice then to recompensate exceptions with TOIL or payment. However, no doubt every single employer will say 'there is no money' and therefore give TOIL. And guess where the TOIL will come from? You guessed it... by leaving the normal working day shortstaffed and abandoning training opportunities (which may have lesser service yields for the Trust).
For exception reporting to work in its design, the BMA need to coordinate its action strongly and support its membership at every turn and process to give trainees confidence that it will work and there are no personal repercussions. Saying 'be brave' is simply not enough. The BMA needs to coordinate its wider membership (especially consultants), talk to Royal Colleges, Health Education England and make clear the issues concerning 'Training vs Service' for today's trainees.
At the end of the day, the most important priority of any trainee doctor is to qualify as GP or CCT. If systems / contracts don't prioritise this, then trainees will not engage with the systems, in order to prioritise their training and career progression.
A very concerned LNC representative.
(I have sent a similar letter to JDC chair.)
The BMA need to give clear guidance and insert in the contract what should be exception reported and what should not. Otherwise Trusts and supervisors will simply pressurise their trainees to 'not report' certain exceptions because of 'differences in opinion' (read as: exploitation).
Cut the Ed sup role. It should go straight to admin.
Breathtaking nativity from the original poster, and from the BMA to caving into these unworkable stipulations at a time of heightened political and fiduciary pressures. They will have virtually no impact on the intended exploitation of doctors by the government pursuing an ideological agenda. The inevitable learned helplessness, disguised as forced-optimism, will do nothing to make this plans viable.
The BMA have no mandate for supporting this contract; the membership have voted against these reforms, which are neither in the best interest of patients or doctors. They have, de facto, handed the government carte blanche to further devalue the medical workforce of this country.
Expect many membership cancellations on the back of this.
I have great concerns re exception reporting it has been linked to fines for the hospital and it means extra work for the educational supervisor so the pressures are all to discourage juniors from reporting
It is so important we get this right as otherwise it will be used by Ministers against you