Guardian of Safe Working

Who we are:

 

Dr Rosalinde Tilley

Guardian of Safe Working

 

Mary Makinde

Project Support Officer

Useful Resources and Websites:

ELFH Supervisor Module

NHS Employers

BMA

What does the new contract mean for me?

Safe working in the new contract

Trainees and trust grade junior doctors are a valued and vital part of our workforce. They play a major role in the day to day management of our patients and are essential to the efficient running of the hospital.

Now working alongside physicians assistants, nurse practitioners and independent prescribers, junior doctors are key to the in-hours and out-of-hours services provided in all departments.

It is important that their working patterns are appropriate, and they are sufficiently rested, in order to provide the safe and high quality care we would want our own relatives to receive.

Doctors in training must be provided with the educational opportunities that their curricula require, to enable them to learn and progress.

The process for monitoring the safe working of junior doctors in the 2016 terms and conditions of training is a significant departure from the previous practice of diary carding.

This website is designed to help trainees, supervisors, managers and rota coordinators to understand and work within the new regulations and answer any questions.

The aim is not to be a slave to the contract, but to utilise these new processes to enhance the educational and working experience for junior doctors, so they are able to work efficiently and provide a high quality of care for our patients while maintaining a good work life balance.

 

The contract in brief

Trainees are now provided with a work schedule comprising; learning objectives, salary information and a rota template that is representative of their expected working pattern.

Human Resources ensure this template is compliant with the safe working rules outlined in the new contract. It should be used by departments to create an operational rota for the trainee’s placement.

Adjustments specific to individuals will be made at the initial meeting between the trainee and their educational or named clinical supervisor. Trainees should then be able to use this personalised work schedule to plan their learning and their lives.

Trainees whose working hours or pattern deviates significantly from this personalised work schedule (due to emergencies, or to ensure service provision) should be free to submit an exception report, documenting these occurrences.

The definition of what is significant is for trainees, to determine, and will vary between trainees, and from day to day for one doctor.

Where this has involved additional hours, recompense should be offered in terms of time off in lieu (TOIL) or payment. This will be agreed at a meeting with the trainee and their supervisor.

Likewise, trainees who miss out on scheduled educational opportunities, or are unable to obtain planned learning objectives may submit a training exception report, and plan alternative arrangements together with their supervisor.

Where exceptions form a pattern, a work schedule review is required to enact organisational or rota changes to prevent recurrences.

The Guardian of Safe Working has responsibility for overseeing the safety of junior doctors working, and provides assurance in this system of exception reporting, and hours and rest monitoring.

The Guardian also chairs the junior doctors’ forum. This is a quarterly meeting where trainees can raise working pattern issues, review exception reporting data, scrutinise the finances accrued from fines, and advise the Guardian on the dispersement of money.

The Guardian’s remit also covers monitoring equality and diversity issues in junior doctors working.

It is important to note that the Guardian is not responsible for devising rotas, Payment problems, or training issues but can direct these queries to appropriate individuals in HR or the Education Centre.

Junior Doctor New Contract Handbook

Terms and Conditions of the junior doctor contract

Junior Doctor Forum

As a part of the new trainee contract, it is a requirement for the trust to hold a quarterly Junior Doctors Forum.

This is a group formed of trainees and key members of the trust (Guardian of Safe Working, Director of Medical Education, Head of HR, Freedom to Speak Up Guardian), who discuss problems pertaining to trainee safe working in the new contract, as well scrutinising fines and agreeing on how they will be spent.

Trainees can experience difficulties being released from their clinical commitments to attend these meetings.

It is a contractual requirement for trainee representatives to be able to attend the Fora, but clearly clinical pressures can be a problem.

In order to guarantee trainee attendance, this commitment should be included in operational rotas for the relevant representatives in lieu of clinical work for these 4 dates each year.

If the representative is scheduled to be on leave/nights or zero hours days, a replacement should be nominated for the meeting and the rota amended accordingly.

Junior Doctors Forum Terms of Reference

Responsibilities of trainee reps (includes upcoming dates)

To find out who your rep is please contact guardianofsafeworking@gstt.nhs.uk

Previous minutes:

12th December 2016

13th March 2017

12th June 2017

 

Guardian of Safe Working reports:

Annual Report 2016-17

Quarterly report April – June 2017

 

Fines that have been levied:

To follow.

Arrangements for Trust Doctors

Guy’s and St Thomas’ NHS Foundation Trust has demonstrated its commitment to junior doctor safe working by extending the ability to exception report for additional hours to this group.

Junior doctors who have not been appointed to a training programme, and are undertaking a fixed term trust doctor post at the trust (starting on or after 2nd August 2017) are eligible to exception report additional hours or missed breaks. This provides them with the same protection as doctors in training, and ensures their working patterns are acceptable, and they are sufficiently rested to provide safe care for our patients.

Additional hours should be remunerated with TOIL or payment as per the guidance for trainees exception reports on this website.  However, additional work by trust doctors cannot incur fines.

As trust posts are for service and experience rather than training, trust doctors are not able to exception report for educational opportunities.

Educational exception reports submitted by trust doctors may be discussed at regular supervision meetings, but the trust is not committed to provide alternative experiences and the report should be closed as non valid.

How to create a generic work schedule and operational rota

Further information to follow.

How to change a rota/working pattern

Further information to follow.

What to do if you have a gap in the rota

Gaps in rotas are problematic for the delivery of the service and can create workloads that are unduly arduous, they are also a common cause of exception reports for late finishes and missed breaks.

Departments should all have clear guidelines for the minimum number of trainees at each grade required to run the service safely. This might be different during the day, at night and at weekends.

This baseline staffing is then used when approving leave, and when deciding what is required to cover gaps.  You should arrange additional staffing whenever a shift has less than the agreed minimum staff at one grade.  The consultant in your department responsible for junior doctor staffing should support you and work with you on developing a plan.

Strategies you can discuss and use are;

  • Formally recruit trust grade staff to backfill a gap – likely to take 6 weeks or more, and may be difficult for doctors with particular skill sets or more seniority
  • Request shifts via staff bank – All training grades (including FY1) are now permitted to undertake work via staff bank, providing they have opted out of the working time regulations. Even if you have some “go to” people who might help, always ensure the shifts are requested in advance through the bank to speed payment. When booking shifts it is essential that the reason for the booking is correctly assigned to “vacancy”. This enables the trust to understand the cost of gaps in rotas and which directorates this is a particular problem for.
  • Flexible use of consultant workforce – This may be more appropriate in some departments, and for some types of work and times of the week, but should be considered and discussed with your responsible consultant.
  • Reduce clinical workload – Where possible or appropriate this may be required (e.g. reducing patient clinic templates or adjusting theatre cases)
  • Reorganisation of previously published rotas – This should not be the first line response as it will certainly result in exception reports, and is disruptive to trainees education and work life balance. Repeated reorganisations of rotas make working conditions extremely difficult, and significantly contribute to trainee dissatisfaction. Good communication is key. Make sure your trainees know how the situation has arisen, and what you have done (and are doing) to solve the problem. Work with your trainees, and ask who would be willing to help. Remember all the safe working rota rules need to be adhered to when shifts are reorganised in this way, and no trainee should undertake more work in swapping shifts (additional work should be through staff bank). As a guide, a trainee who is willing to work a 13 hour night shift should be relieved of two 9 hour day shifts in lieu as this is approximately equivalent in pay.  This trainee can submit a “difference in work pattern” exception report so the frequency of changes to their working pattern is documented, but they have already received their recompense.

Roles of the faculty lead/college tutor/educational supervisor/clinical supervisor

  • A junior doctor on a training programme who is working in the same department as their Educational Supervisor will have their ES nominated by the DRS system to meet with the trainee and agree an outcome.
  • A junior doctor on a training programme working in a different department to their Educational Supervisor will have their named Clinical Supervisor in that department nominated to manage their exception report. This is usually for Foundation Trainees, Core Medical Trainees, ACCS Trainees, or ICM Trainees undertaking complimentary training in medicine or anaesthetics.
  • The system currently does not allow your ES to have read only access to your exception reports. Therefore the trainee and named CS should agree who will inform the ES of the outcome. In any case the trainee should discuss the outcome of any exception reports submitted with their ES at the next scheduled meeting.

What do I need to do before a trainee starts?

Work schedules must be sent out 8 weeks before the trainee’s start date. Leave requests must then be made at least 7 weeks before the trainee’s start date,  and an operational rota must be sent out 6 weeks before the trainee’s start date.

For further information please see the ‘Work Scheduling’ podcast under the ‘Podcasts’ tab.

How do I manage a gap in the rota?

Gaps in rotas are problematic for the delivery of the service and can create workloads that are unduly arduous, they are also a common cause of exception reports for late finishes and missed breaks.

Departments should all have clear guidelines for the minimum number of trainees at each grade required to run the service safely. This might be different during the day, at night and at weekends.

This baseline staffing is then used when approving leave, and when deciding what is required to cover gaps.  You should arrange additional staffing whenever a shift has less than the agreed minimum staff at one grade.  The consultant in your department responsible for junior doctor staffing should support you and work with you on developing a plan.

Strategies you can discuss and use are;

  • Formally recruit trust grade staff to backfill a gap – likely to take 6 weeks or more, and may be difficult for doctors with particular skill sets or more seniority
  • Request shifts via staff bank – All training grades (including FY1) are now permitted to undertake work via staff bank, providing they have opted out of the working time regulations. Even if you have some “go to” people who might help, always ensure the shifts are requested in advance through the bank to speed payment. When booking shifts it is essential that the reason for the booking is correctly assigned to “vacancy”. This enables the trust to understand the cost of gaps in rotas and which directorates this is a particular problem for.
  • Flexible use of consultant workforce – This may be more appropriate in some departments, and for some types of work and times of the week, but should be considered and discussed with your responsible consultant.
  • Reduce clinical workload – Where possible or appropriate this may be required (e.g. reducing patient clinic templates or adjusting theatre cases)
  • Reorganisation of previously published rotas – This should not be the first line response as it will certainly result in exception reports, and is disruptive to trainees education and work life balance. Repeated reorganisations of rotas make working conditions extremely difficult, and significantly contribute to trainee dissatisfaction. Good communication is key. Make sure your trainees know how the situation has arisen, and what you have done (and are doing) to solve the problem. Work with your trainees, and ask who would be willing to help. Remember all the safe working rota rules need to be adhered to when shifts are reorganised in this way, and no trainee should undertake more work in swapping shifts (additional work should be through staff bank). As a guide, a trainee who is willing to work a 13 hour night shift should be relieved of two 9 hour day shifts in lieu as this is approximately equivalent in pay.  This trainee can submit a “difference in work pattern” exception report so the frequency of changes to their working pattern is documented, but they have already received their recompense.

What are the responsibilities of my trainee reps?

Payment and TOIL from exception reporting

Further information to follow.

Educational Supervision List

Further information to follow.

Accommodating Leave

Further information to follow.

I’ve forgotten/didn’t receive my login?

If you have not received your login or you’ve forgotten your details you should please emailGuardianofsafeworking@gstt.nhs.uk for new login details.

I am having trouble accessing the DRS website.

Please check whether the browser you are opening the website from is compatible with the site. On old Trust computers the DRS website can only be accessed via Google Chrome or Mozilla Firefox.  If you are still having trouble gaining access please email Guardianofsafeworking@gstt.nhs.uk so we can look into this for you.

How do I change my supervisor?

You can change your supervisor by informing the PSO Mary Makinde via email at Guardianofsafeworking@gstt.nhs.uk

What if my Educational Supervisor does not work in the same department as me?

Further information to follow.

What can be reported via exception reports?

Further information to follow.

Who will be designated to handle my exception report?

  • If you are on a training scheme where you are working in the same department as your ES, then this is who will be nominated by the DRS system to meet with you and agree an outcome.
  • If you are on a training programme where you work in a separate department (or hospital) to your ES, then your named clinical supervisor in that department will have been nominated to manage your exception report. In general this is:
  • Foundation Trainees
  • Core Medicine Trainees
  • ACCS Trainees (EM, AM, Anaes)
  • ICM trainees undertaking complementary training in medicine or anaesthetics
  • If the system allows then you should also nominate your ES to have read only access to your exception reports. The DRS system does not currently do this and therefore you and your named CS should agree who will inform the ES of the outcome. In any case you should also discuss the outcome of any exceptions you have submitted with your ES at the next scheduled meeting

What is the timeframe for exception report submission?

  • Reports should be submitted as soon as possible and in any case within 14 days
  • Reports should be submitted in 7 days if payment is requested
  • Reports should be submitted within 24 hours where there are immediate safety concerns. Please tick the safety concerns box on the submission form and provide free text details on the specific safety concerns

When should I submit an exception report?

If a trainee’s hours deviate significantly or regularly from their work schedule then they should inform their department that this has occurred at the time, or as soon as is practicable in advance. Normally this would involve a discussion with the senior clinician supervising them that day.They may also wish to complete an exception report via the DRS website. Exception reports can also be submitted if you miss an educational event (i.e. teaching sessions) due to your workload.

What if an exception happens when I am on an out of hours rota?

Further information to follow.

I have had more than one exception on one day, what should I do?

  • This is a common occurrence as bad days tend to impact on the ability to take a break and also result in late finishes
  • Each incidence requires a separate exception report. Incidences should nto be “bundled” together in one report as the causation as well as the agreed outcomes may be different (TOIL or payment)
  • If anumber of exception reports are made in a short period, then they may all be dealt with at the same meeting with the appropriate supervisor

What else should I do when I complete an exception report?

Further information to follow.

Do I have to submit an exception report, and how do I take into account days when I leave early?

  • The trust supports trainees’ right to exception report. The GOS encourages you to participate fully in the process of raising exception reports, in a professional manner and hope that you will feel free to do so with confidence during your time at GSTT
  • Trainees are not obliged to submit an exception report for additional work or a difference in work pattern. The choice is your to decide what constitutes a “significant” difference from your work schedule. This will mean different things to different trainees at different times
  • Workloads vary from day to day and at different times of the year. Winter pressures should be balanced against a somewhat easier summer period in some departments for longer placements. When making the decision to submit an exception report on the basis of hours, trainees should take into account early finishes as well as additional working and the impact on their lives.
  • It is expected and trusted that trainees, educational supervisors and departmental leads will take a professional attitude to trainees working patterns and recognise when workloads are excessive.

When does additional work not require an exception report?

If a trainee has agreed in advance to accept remuneration to undertake additional work to be paid via the staff bank, then this does not require an exception report, as the additional hours will be captured by the staff bank.

If a trainee wishes to stay after the scheduled end of their shift to follow up on an area that interests them, they are at liberty to do so. If however, the training opportunity is a requirement for their stage of training, and not accessible in another way, then an exception report should be completed and TOIL agreed. This TOIL could then be taken during a future service shift as the additional time represented training.

What breaks am I entitled to in the new contract?

  • It is important for staff to be able to take adequate breaks during their daily work. Taking breaks is essential for the health of both staff and patients and contributes to efficient and effective safe working.
  • Trainees are expected to be able to take a 30 minute break in a 5 hour shift and an additional break of 30 minutes for shifts lasting over 9 hours.
  • Workloads and rotas should be devised to enable breaks to take place as the norm.
  • Taking a break should be seen as a patient safety issue by trainee and department alike and therefore prioritised on this basis
  • It is appreciated that unexpected emergencies and workload pressures can occur that can impact on taking breaks.
  • If a trainee is unable to take an appropriate break, they will be expected to raise the issue at the time with the department whenever possible via a locally agreed process.
  • Given that breaks are missed due to excess workload, departments should have efficient processes in place to ensure missed break reporting can be enacted swiftly and easily whatever the circumstances e.g. a designated number to call or text. This should be made clear during local induction for the post
  • Once notified the department should put additional measures in place in real time to support the trainee (e.g. break relief by a colleague or senior). This will enable appropriate validation of any subsequent exception report the trainee submits if the breaks are still unable to be taken.

What if I am asked to work a shift but I will breach the rules?

Further information to follow.

Can I swap shifts with colleagues?

Further information to follow.

What should I do about exception reporting staying late when I have only just started?

  • Trainees often feel reluctant to exception report very early in a placement, attributing late finishes to “getting to know the job” and early days inefficiency.
  • Everyone does become more efficient during a post, and trainees are expected to make some adjustment for this when considering exception reporting. At the same time, it is important to flag up to a department at an early stage when workloads are truly excessive, and unlikely to even out in this way.
  • Rota start and finish times need to be accurate and take into account the rotational nature of junior doctors’ working patterns , and the learning curve that is inherent in this workforce model.

I am feeling discouraged to exception report, what do I do?

Further information to follow.

How do I close a report?

Further information to follow.

What do I do if my report is not closed?

Further information to follow.

What do I do if I am not happy with the outcome of my report?

Further information to follow.

What actions can be taken for an exception report?

  • Upon receipt of an exception report the ES, or named CS, will discuss with tyou what action is necessary to validate and address it. Once validated, one of two actions will be agreed
  • No action needs to be taken on this occasion
  • Compensation in the form of payment will be made
  • Time off in lieu is required
  • You may express a preference for TOIL or payment, but the final decision of these to methods of remuneration lies with your supervisor
  • If an exception report is deemed to be part of a pattern then a work schedule review needs to be undertaken by your supervisor in conjunction with the department. Further options at this point are:
  • No action to be taken
  • A change to the work schedule is required (e.g. extending the working day)
  • Organisational changes are required (e.g. timing of ward rounds or clinics, arrangements for handover of information, additional manpower identified)
    • Single instances of a few minutes would not normally be considered a significant deviation from a work schedule.
    • If an exception report or series of reports has been validated and applies to ≤1 or ≥4additional hours worked or braks missed, then it would normally be taken as time in lieu, unless the rota, workload or remaining time on placement prevent this.
    • If an exception report or series of reports has been validated and applies to 1-4 additional hours worked, then complenation may be in the form of payment
    • Before agreeing payment, your supervisor will consider your scheduled working hours and previous exception reports, to consider if the additional work would result in you working >48hours over a rota cycle. This is deemed to be unsafe and would result in the department incurring a find. You and your supervisor should work together to prevent this if possible
    • Your supervisor should inform your local service manager/general manager when payments have been agreed, so that they can enact payment
    • Payments are normally included in your monthly salary within 6 weeks, and will appear on your payslip as “overtime”. If this is not the case please email the GOS Guardianofsafeworking@gstt.nhs.uk
    • Your supervisor should inform the department rota coordinator of agreed TOIL. This should normally be taken at the next suitable day on the rota that the trainee has not booked as annual or study leave, and where the staffing levels can support the leave to be taken without creating exception reports from other trainees
    • All TOIL should be taken within 1 month of agreement
    • TOIL cannot be taken during H@N shifts, and exception reporting of additional work or missed breaks overnight will normally be paid
    • Any valid exception reports for additional hours worked that has not been closed, or where TOIL has not been taken, prior to you finishing a placement will be paid
    • TOIL should not normally exceed 8 hours in any rota cycle. Additional hours of this magnitude worked (and validated through exception reporting) would normally prompt a work schedule review

If I have an exception report validated does it apply to all trainees on my rota?

  • Exception reports may apply to a particular trainee. If a report(s) highlight a potential pattern then a work schedule review would be undertaken. Changes made as a result of a work schedule review may affect an individual or a number of trainees
  • The meeting with your ES/named CS will play a part in determining which the case is. In addition the frequency of reports and the number of different doctors submitting reports will be taken into account
  • Exception reports will be monitored by the Guardian of Safe Working, who may arrange to meet with all doctors on the same rota to establish working patterns
  • The GOS will determine if reports affect individuals or to all doctors on a rota.

A trainee is scheduled to work a night shift on the last day of their placement, what happens when they rotate?

The normal process is for the trainee to undertake the night shift in their previous placement, and have a zero hours day on the first day of the new rotation.

 

The new department needs to arrange for a separate induction in these circumstances, to accommodate the zero hours days required after a night shift.

A trainee must not be asked to attend induction after working a night shift.

 

If the night shift was the 4th in a run, then the new department will need to make allowances for two zero hours days (not just one) at the start of the placement.

 

The alternative is for the new department administrators to liaise with the trainees previous placement coordinators, and a locum found for the last night.

It is not the department and not the trainee’s responsibility to arrange this.

 

It is important for all trainees to inform their new departments if this situation applies in a timely manner, that arrangements can be made (at least 8 weeks prior to rotating is the minimum).

This will enable plans to be incorporated into the operational rotas sent out 6 weeks prior to rotating.