Guardian of Safe Working hours Dr Sunil Nair Consultant Physician

Background The new contract requires (schedule 6) all NHS employers to have a Guardian of Safe Working Guardian must be a senior person, independent of the management structure within the organisation The new contract negotiations failed which led to 2 strikes in Jan & Feb 2016 Jeremy Hunt said he will impose the new contract anyway More strikes in March & April BMA junior doctors committee, NHS Employers & the secretary of state negotiated a new contract on 18/May/2016 The junior doctors however rejected the new contract & more strikes were planned for the autumn and winter this year. Due to overwhelming concerns about patient safety, these were withdrawn The new junior doctors contract is being implemented in a phased manner over the year; the first doctors to start on it are the F1s starting in our trust in December this year.

Why do we need a guardian? Current twice-yearly monitoring mechanism is not a good measure of rota safety BMA, DH and NHS Employers agreed a new system of work scheduling and exception reporting in 2013/14 negotiations Junior doctors concerned that employers may not act on exception reports It was agreed that there should be an independent person responsible for championing safe working hours Everyone agrees that the current monitoring system is not fit for purpose. It is dependent on a high percentage of response rate to be valid and moreover it is far too retrospective; most junior doctors are preparing for their next job move. The engagement with it has traditionally been very poor. Penalty bandings mean that health and safety issues are unhelpfully conflated with pay, preventing issues from being resolved

Responsibilities Protecting the safeguards outlined in the 2016 TCS for doctors and dentists in training Ensure issues of compliance with safe working hours are addressed, as they arise Provide assurance to the Trust Board that doctors‘ working hours are safe Champion of safe working

Assurance to the Trust Board Guardian’s Report to the board every quarter (rota gaps, exception reports, trends etc..) A consolidated annual report to be included in the Trust's Quality Account (signed off by CEO) If an issue escalated by the guardian remains unresolved: submit an exceptional report to the next meeting of the Board The Board is responsible for providing annual reports to external bodies: HEE, CQC, & GMC. Also made available to the LNC

The guardian will not: Design rotas Manage individual work schedules Act as the educational champion Review every aspect of doctors’ working patterns Intervene in every exception Agree working patterns or schedules with individual doctors Answer questions which fall outside their remit - though should know where to direct the doctor for further help (e.g. medical staffing or the BMA)

Distinction between roles The guardian is not responsible for education and training, this remains the role of the DME The guardian is not responsible for the line management of junior doctors (unless this was already part of their separate role as a clinical/educational supervisor) The guardian role does not replace the role of educational supervisors The guardian of safe working hours should not be confused with other guardian roles such as the Caldicott guardian or Freedom to Speak up guardian.

The main instruments of safeguards in the new contract Personalised work schedules Exception reporting Work schedule reviews

Work schedules Employers to design work schedules safe for patients and doctors & adhere to it in delivering services Educational planning & Clinical planning Generic work schedules to be provided before commencing post Personalised work schedule to be developed by Ed.supervisor & the junior doctor at the first formal meeting

Exception Reporting The system of exception reporting outlined in the 2016 contract will ensure recording of departures in planned working hours working pattern or access to planned training opportunities Work schedule reviews should take place where this happens consistently and can be requested by the employer or the doctor 

Exception reporting: DRS (doctor’s rostering system) Web based application that works across desktop, tablet & smartphone Allows doctors to submit exception reports and view updates on previously submitted reports Allows educational supervisors to review and action reports Provides guardian and DME with visibility of exceptions across their organisation

Example 1 Dr A is an ST3 in OBG: receive a generic work schedule prior to starting in posts & soon after with their Edu. Supervisor personalises it in accordance with their training needs and the opportunities in the post After a few weeks Dr A feels that he is not able to achieve a particular learning objective in the work schedule because he is never working on the day that procedure takes place Dr A raises an exception report, copying the DME as the issue is related to training

Example 1… Dr A’s educational /clinical supervisor reviews the exception report & agrees that in order to achieve this particular learning outcome, the work schedule should be changed to allow Dr A to access the training opportunity The educational/clinical supervisor makes the necessary arrangements, and communicates this outcome to the doctor, copying the DME

Example 2 Dr C on the third Thursday after starting the placement, was supposed to finish at 18.00 but could not leave until 19.00 Exception report (copied to the guardian of safe working hours, as this is a working time issue) as she feels that she could not have left work on time due to a patient safety issue The supervisor reviews the report, agrees, and makes the necessary arrangements for Dr C to receive TOIL (time off in lieu) the following Tuesday morning for the extra hour she has worked

Example 2… This outcome is communicated to Dr C and copied to the guardian Payment for the extra hour of work may also be an option but was not required as TOIL (time off in lieu) is usually preferred However, over the next few weeks, Dr C raises further exception reports on the following two Thursday evenings as well However, over the next few weeks, Dr C raises further exception reports on the following two Thursday evenings as well, because on each occasion, she had to stay at work beyond the time when the work schedule says that she should finish

Example 2…. Reviewing these exceptions: clearly not a one off situation but is a systemic issue After reviewing the exceptions with Dr C, the supervisor concludes that it is not possible to complete the work on Thursday afternoons by 18.00,and therefore a work schedule review is required They agree her finishing time on Thursday needs adjusting from 18.00 to 19.00 in the work schedule, with her salary adjusted to reflect this. The outcome is copied to the guardian for reference Reviewing these exceptions, the educational supervisor realises that this is clearly not a one off situation but is related to some form of more systemic issue After reviewing the exceptions with Dr C, the supervisor concludes that it is not possible to complete the work on Thursday afternoons by 18.00,and therefore a work schedule review is required They agree that her finishing time on Tuesday has to be adjusted from18.00 to 19.00 in the work schedule, with her salary being adjusted accordingly to reflect this. The outcome is copied to the guardian for reference

Exception reporting interfaces Doctor interface Supervisor interface Admin interface

Doctor Interface Through the doctor interface you can:Create and submit new exceptions related to hours/rest& education issues View the status of previously submitted exceptions View any comments added by supervisors and others Add comments to existing exceptions

Supervisor interface Educational supervisors can do the following through the educational supervisor interface:Review exceptions submitted by their doctor Agree or disagree with the exception For agreed exceptions, note if any payment or time off in lieu is required Add comments to exceptions •When one of your trainees submits a new exception, you will receive a notification email •Whenever you take action or add a comment to an exception, the doctor will receive a notification email letting them know you have updated the exception •Once you have taken action on an exception and agreed or disagreed, you will not be able to make further changes

Admin interface Med staffing, DME & the Guardian Guardians’ dashboard exception reports not actioned/delayed Are there any patterns >1 doctor reporting the same part of the rota Same doctor reporting several exceptions Many reports from a particular grade of doctors Same supervisor No report from a department

Exception Reporting Doctors should report exceptions where day-to-day work varies from that set out in the work schedule They must be submitted within 14 days (standard) 7 days if payment is requested 24 hours where there are immediate safety concerns Any issues should at first be addressed by their supervisors, to establish whether this is truly exceptional or whether it requires a work schedule review

Exception reporting You can exception report virtually anything – it is a quick and easy way of flagging to your employer that something is wrong: Work extra hours Not meeting your training needs Haven't been able to take your breaks Doing more hrs. on-call than in your prospective estimate

Exception reporting.. Copied to the Guardian (or the DME) to ensure the problem is dealt with in a timely way: acting as an independent arbitrator in any disagreements between you and your manager If you feel pressured or bullied into not filing an exception report by any of your colleagues or your manager, raise this with the guardian.

Potential situations where Guardian fine applies Maximum 48 hours average working week Maximum 72 hours in any 7 consecutive days At least 11 hours consecutive rest between rostered shifts 30 minutes break for 5 hours worked, a second 30 minute break for >9 hours

Guardian fines Fines levied against the department where the doctor works, at 4x the applicable rate of pay for the time of the breach The doctor will receive 1.5 times the applicable locum rate, and the guardian will retain the remainder for future disbursement

Exception Report Flow Chart Trainee works outside work schedule & raises exception report Sent to supervisor: reviews & discusses reasons with trainee Workplace requirement for additional work Payment or TOIL agreed Clear trainee choice to stay late, start early, or miss break Copy to the guardian

Exception Report Flow Chart Payment or TOIL agreed Is issue one-off or a pattern Pattern Level 1 work schedule review One- off Close & notify guardian Notify guardian

Conclusions The new junior doctor’s contract is being phased in over the next year As supervisors we need to ensure the safeguards provided in the TCS are also implemented in the interest of our juniors Junior doctors should make sure they engage with the exception reporting process

Thank you..