England Junior doctor

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Make no exceptions on safety at work

FY2 Adele Flowerdue and George Allan at work in the emergency department of North Manchester General hospital. manc160915. full consent.

This week, the BMA is launching an ‘exception reporting, no exceptions’ week of content. It will include information and insights from junior doctors and consultants about how to get the best out of exception reporting. Peter Blackburn explains the system

The NHS is chronically underfunded and faces unprecedented strain.

Rota gaps, recruitment shortages and unforeseen service pressures have become the everyday realities of life working in England’s hospitals.

But these pressures can’t be allowed to mount on junior doctors working on the front line and hospital managers can’t expect trainees to cover service gaps while breaching safe working limits.

It is for these reasons that doctors leaders negotiated safeguards during contract talks with NHS Employers last year.

For the first time – thanks to the exception reporting system negotiated by the BMA – junior doctors have a system to report breaches in hours, breaks missed, and educational opportunities lost. They also have an independent voice to champion safe working in their organisations, and hospital trusts in

England face financial penalties for overworking trainees.

The exception reporting system provides a voice for junior doctors, an advocate for their efforts, and an opportunity to build a bank of data to show managers and government officials where issues lie – and the scale of the problems.

As a foundation doctor, Martha Martin recently wrote on the BMA website: ‘Statements about working over hours or while understaffed will no longer be anecdotal but rooted in hard evidence.’

These tools can be a safeguard and an early warning system, and could help shock employers and the Government out of any delusions they may have about working hours.


What is exception reporting?

The purpose of exception reporting is for doctors to be able to raise any instance when their work or training varies from what was planned.

Reasons for an exception report can include ward staffing being below necessary levels, a rota being unworkable, breaks being cut short, or staff having to work before or after hours just to get the job done.

It is not a measure of the performance of junior doctors – it is designed to highlight any problems in the system and ensure safe working limits are complied with. It should allow trusts to respond quickly and address any areas where problems are arising.

Fundamentally, the system means junior doctors are either paid or given time off in lieu for any time they work beyond rostered hours.

Trusts can also be fined if they work beyond the legal upper safety limits, with the money being spent on initiatives which will benefit junior doctors and a penalty rate paid to the trainee.


What is the guardian of safe working hours?

During the negotiations over the new contract, the guardian role was introduced to champion the safety of all trainees.

It is independent from the management structure of hospitals and must represent – and act as an advocate for – junior doctors having issues related to working hours. Guardians will report directly into trust boards and also be held to account by junior doctors’ forums and local negotiating committees.

The role requires a quarterly report to be submitted to the trust’s board detailing exception report trends and areas of concern.


How does exception reporting work?

The format of exception reporting varies from hospital to hospital but the new contract states that all trusts must have an electronic system in place, whether through an app or online form – or email at a minimum.

In most hospital trusts one of two pre-existing software packages are used to make the process quick and easy for trainees.

The details of the exception are filled out in the form and the report will be sent to the trainee’s educational supervisor.

The supervisor will have seven days to assess the exception report and provide a response or discuss next steps with the trainee.

On top of this, the guardian should be copied into any exception report based on safe working issues and the director of medical education should be copied into any report related to training.

Where it is deemed to be of benefit to trainees, an educational supervisor may nominate a clinical supervisor to deal with exception reports on their behalf, owing to their knowledge of the department and rota.

However, this should only be agreed in accordance with local negotiating policy and with consent from the junior doctors affected. Any such arrangement should be explained to trainees in advance, and the educational supervisor retains overall accountability for the process.

Simple flow charts of how to report different types of exceptions


What should you exception report?

Trainees should exception report issues as they arise, such as differences in the total hours worked from what was set out in the work schedule – including differences from the prospective estimate of hours actually worked while non-resident on call – rest breaks not taken, educational or training opportunities missed and levels of support available during service commitments.

Exception reporting is every trainee’s right and contractual responsibility. There are no restrictions on what should be reported or indeed how many reports can be submitted. Furthermore, there is no pre-authorisation or sign-off process required before an exception report can be submitted.

Exception reporting is the mechanism to ensure that training can be protected, workloads kept manageable and safeguards maintained for your health and the safety of the patients trainees look after.


Why is exception reporting important?

Exception reporting provides solutions to problems doctors have faced on a personal, and collective, level for years.

On an independent basis junior doctors now have the ability to catalogue the extra hours they work, the reasons why and the everyday realities that make the job difficult. Access to compensation either in the form of additional pay or time off to rest means that trainees no longer have to tolerate ‘goodwill’ overtime.

But the system also represents an opportunity to show managers and politicians the data that will demonstrate the difficulty of doctors’ working lives.

No longer will comments about doctors working extra hours, or hospital wards being under-staffed, be anecdotal. Instead, cold, hard data will provide context, and answers.

The clear truth is that for the system to work to its fullest all juniors doctors must use it and employers must show junior doctors’ concerns the respect they deserve.

But most of all trainees must not allow pressure from colleagues or other concerns to cloud the process of exception reporting. An hour of extra work here or there can soon add up and failing to report this will not paint a genuine picture of the problems on hospital wards.

In other words: exception reporting, no exceptions.


How is it working so far?

Signs on the ground so far are positive, with guardians in place across the country and many junior doctors already becoming engaged with the system.

In January guardians will report to their trust boards detailing their work so far – and how compliant rotas are with the rules of the new contract.

There have already been some encouraging results from around the country, which will be reported on.

Find out more

Read London specialty trainee 2 Chris James's blog on exception reporting



Myth and reality

MYTH: The reporting system is excessively cumbersome.

REALITY: Exception reporting should be relatively quick and easy – particularly once junior doctors have become used to the system or software used by a trust. The form only asks a few simple questions and should be quite a smooth process. The BMA junior doctors committee is working with software providers to ensure the systems are effective and easy to use for trainees.

MYTH: Your exception reports will become mired in bureaucracy.

REALITY: The process is designed to be simple and smooth with exception reports passed up a chain of recipients if necessary. The initial respondent has a set period of seven days to respond so the process will be carried out quickly.

MYTH: It won’t change anything.

REALITY: Things are already changing. Areas of the country are already seeing junior doctors
paid for the actual time they work or being given time back. And at least one hospital trust is employing more staff as a response to concerns raised by the system.

MYTH: The guardians will be too busy to respond to the reports.

REALITY: Each guardian must report to the trust board on a regular basis and many of these reports will be public. Being too busy will simply not be an excuse and many guardians have already put a lot of work into ensuring the process has teeth and is as smooth as possible.

MYTH: The guardians will be hostile.

REALITY: The guardians who have taken up roles have done so because they want to be part of the system, and the role is to be an advocate for junior doctors and a champion for safe working hours. The contract details the performance review process for the guardian, and the steps junior doctors can take to challenge a guardian who is not acting independently.

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