1. Guardian of Safe Working hours
Dr Sunil Nair
Consultant Physician

2. 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 Due to overwhelming concerns about patient safety, these were withdrawn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.

3. 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

4. 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

5. 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

6. 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)

7. 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.

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

9. 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

10. 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 

11. 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

12. 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

13. 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

14. Example 2
Dr C on the third Thursday after starting the placement, was supposed to finish at 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

15. 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

16. 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 to 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 in the work schedule, with her salary being adjusted accordingly to reflect this. The outcome is copied to the guardian for reference

17. Exception reporting interfaces
Doctor interface
Supervisor interface
Admin interface

18. 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

19. 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
•Whenever you take action or add a comment to an exception, the doctor will receive a notification 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

20. 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

21. 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

22. 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

23. 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.

24. 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

25. 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

26. 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

27. 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

28. 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

29. Thank you..