Exception Reporting – Guidance for Doctors in Training and Consultants
Written by Dr Abi Langrish, Dr Adalina Sacco, Dr Jane MacDougall and Dr Jo Mountfield
Purpose of Exception Reporting
Under the new terms and conditions of service for doctors in training, which came into effect in 2016, doctors in training have a new system for monitoring hours and to ensure safe working. Since the new contract came into effect doctors in training must be provided with a work schedule outlining their rota template and educational opportunities. When their actual work varies significantly and regularly from their work schedule or training opportunities are missed, they should file an exception report.
Exception reporting, if managed well, can provide a faster and more responsive mechanism to identify and address unsafe hours, thereby reducing workload as well as improving patient safety and the quality of training.
When to Exception Report
Exception reports must be sent electronically. There is a wide variation from hospital to hospital in exception reporting tools such as email, desktop apps or other software. Doctors in training and consultants alike should be trained how to access the system that is in place in their hospital.
Exception reporting provides the trainee with the opportunity to raise concerns in the following areas; this list is not exhaustive as there is no restriction on the topic that is reported:
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Differences in total hours worked compared to those set in the work schedule.
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Patterns of hours worked
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Rest breaks not taken (one 30-minute break for a shift of more than 5 hours and a second 30-minute break for a shift of more than 9 hours).
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Educational and training opportunities missed.
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Levels of support available during shifts.
Patient Safety - Exception reporting should also be used to raise concerns over doctors in training safety and patient safety. Where there are immediate concerns over safety, for example due to doctor’s illness, understaffing or exceptionally high workloads, the consultant in charge of the service should be verbally informed immediately. An exception report should also be filed to ensure if necessary there is a long-term resolution of the issue.
What Happens Once an Exception Report is Made
An exception report should be filed within 14 days of the event. Once the report is filed the education supervisor will be notified along with the guardian of safe working hours if it regards safe working hours or director of medical education if pertains to missed educational opportunities. There may be local variations on who is notified within the department of exception reports made, for example it may be the responsibility of the local rota lead or college tutor. The educational supervisor or named person should meet with the trainee within 14 days of the report being made.
At the exception report meeting the trainee and educational supervisor should discuss why the report has come about and find a mutually agreed action to address the issue. Usually an agreement is reached, usually for time off in lieu or payment for extra hours worked. If a solution that is agreeable by both parties cannot be found, this should then be raised with the guardian for safe working hours or the director of medical education as a “level 2 work review” which is further explained below.
Barriers to Exception Reporting
There maybe perceived barriers to exception reporting, such as being a trouble maker, placing more stress upon the system for time off in lieu as compensation or leading to breakdown in relationships. However, exception reporting in the only formal mechanism there is for protecting doctors in training workload and maintaining safety for doctors and patients alike.
It is important to recognise that exception reporting is not about apportioning blame, nor is it a reflection upon personal performance, but is a tool to address problems within the existing NHS service and is a part of the existing 2016 junior doctors contract. This system is fully supported by the GMC. Exception reporting provides real time data that can effect change in hospitals, whether it is extra posts, reallocation of tasks to other professional groups or provision of additional resources.
Consultants 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.
Outcomes from Exception Reporting
Following the meeting between trainee and educational supervisor it may be decided that no immediate action needs to take place, e.g if the reason for the report was a “one-off”.
Impact on pay – If an exception report has been submitted for working hours beyond those contracted, then a discussion should take place for compensation. This may involve being paid for extra hours or time off on lieu. If payment is made for extra hours worked, the hourly rate should reflect the time of day and day of the week that the work occurred in. Payment for extra hours worked can also act as a disincentive for the employer, reflecting that doctors in training should not be overworked. The aim for this is to recognise that doctors in training will often work extra hours to care for patients, but also to encourage a safe working environment. If an exception report is linked to being paid for extra hours worked then that report should be filed within seven days of the event.
Time off in lieu – Again if an exception report has been submitted for working hours beyond those contracted, compensation can be provided in the form of time off in lieu.
Breach of contract incurring financial penalty - Although most exception reports will result in either payment for the additional hours worked or TOIL, there are circumstances where financial penalties will be levied against the trust. The following situations will automatically result in a financial penalty:
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working more than 48 hours average per week
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working more than 72 hours in any seven consecutive days
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rest between shifts is reduced to less than eight hours
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missed breaks on 25% of occasions (across a four-week reference period)
These fines are automatic and it is the responsibility of the guardian to review all exception reports copied to them, in order to identify if any of the above breaches have occurred. In such circumstances, TOIL cannot be negotiated as a replacement for the fine. Fines are taken from department budgets and are used by doctors in training for educational activities and therefore can act as a driver to improve trainee welfare.
Work schedule review – If shift overruns are frequent, it maybe necessary to review the work schedule to ensure the extra hours worked are represented in the work schedule and salary is adjusted accordingly. A work schedule review can be requested at anytime if the trainee, supervisor or guardian of safe working feels that the current work schedule is not fit for purpose. The review may result in the following:
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No work schedule changes are required, and extra hours can be compensated with payment or TOIL
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Prospective changes to the work schedule are made with an adjustment to salary if required.
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Organisational changes are required, for example, timing of ward rounds, start and finish times of clinics.
The outcome of any changes should be communicated in writing to all of those involved. If the junior doctor or supervisor are not happy with the proposed changes a level 2 work review can be requested. The level 2 work review must be requested within 14 days of receiving feedback from the first review. An explanation of why you are not happy with the first review and what you would like to happen will need to be included.
A level 2 work review should take place within 21 days of it being filed. A meeting must be held involving the junior doctor, educational supervisor, a service representative and the guardian of safe working (if hours related) or the director of medical education (if training related). If any party is still not happy at the end of this process a final work review can be requested as part of the local employer’s grievance procedure and should involve the BMA. Please refer to the NHSE website for specific algorithms for this process.
Example
Sarah is an ST5 Obstetrics and Gynaecology trainee, since moving to her new rotation hospital she has found herself working late every Tuesday evening after an all-day theatre list. Sarah has left late to ensure that patients have had their post-operative care or have been discharged, meaning that she is not finishing work until 18.30, 1.5 hours beyond contracted hours. Sarah submitted an exception report and met with her educational supervisor with the guardian of safe working copied in. At the meeting it has been acknowledged that this a weekly occurrence over a four-week rota cycle and therefore a work schedule review needs to take place. Her work schedule has been amended and her salary adjusted to recognise these hours worked. Alternatives solutions could be time off in lieu or arranging another professional to do these duties. All changes were agreed upon and the guardian of safe working made aware.
References
www.BMA.org.uk/exception reporting
NHS Employers – www.nhsemployers.org
Exception reporting guidance. University Hospital Southampton. March 2017.