Someone to Watch Over Me

The Role of the Guardian for Safe Working Hours

Dr Tony Rao

South London and Maudsley NHS Foundation Trust

Background • Agreement reached during 2013/14 junior doctor contract negotiations to replace existing system with one of work scheduling and exception reporting • Proposal put forward to have an independent person responsible for championing safe working hours • Later agreed that this person would have the power to fine the employer where safety rules are breached • BMA, HEE and NHSE continue to endorse role of the Guardian

Safe Working Hours

Improving training experience means…

adequate time for safe working and acquiring training

competencies

Why should there be Exception Reporting (ER)

• Provides an overview of the quality of training and patient care

• Protects work-life balance

• Improves departmental awareness

• Informs workforce planning

• Trigger to quality improvement in MDT working

• A mechanism for improving job satisfaction and overall training experience

Exception Reporting (ER) • Mechanism to inform employer when day-to-day work varies from agreed work schedule

• ER may trigger a work schedule review • ER should include: name, specialty, grade of junior doctor (JD); name of educational

supervisor (ES); dates, times and durations of exceptions; nature of variance from the work schedule; outline of steps doctor has taken to resolve matters before escalation (if any)

• Doctor will send ER electronically to ES as soon as possible after exception takes place and certainly within 14 days. JD will copy ER to the director of medical education (DME) in relation to training issues, and to GSWH in relation to safe working practices. In some cases, may copy the report to both

• Upon receipt of an ER, ES will discuss with the JD action necessary to address reported

variation or concern. The supervisor will set out the agreed outcome of ER, including any agreed actions, in an electronic response to the doctor, copying the response to the DME or guardian of safe working hours as appropriately identified above

• DME or GSWH will review the outcome of the exception report to identify whether further

improvements to the doctor’s training experience/working hours are required

Types of exception that need to be reported

1. EXCEDING WORKING HOURS AND NOT ACHIEVING REQUIRED

BREAKS

i. Early Start

ii. Late Finish

iii. Unable to achieve breaks

iv. More than 72 hour working week

2. NOT GAINING REQUIRED EDUCATION/TRAINING OPPORTUNITIES

Safe Working Hours breaches incurring a financial penalty GSWH will review all exception reports copied to them by doctors to identify whether a breach has occurred which incurs a financial penalty Where concerns validated and shown to be correct in relation to: - Breach of 48-hour average working week (across the reference period agreed for that

placement in the work schedule) or - Breach of maximum 72-hour limit in any seven days or - Minimum 11 hours’ rest requirement between shifts has been reduced to fewer than eight

hours • The doctor will be paid for the additional hours at the penalty rates; GSWH will also levy a

fine on department employing the doctor for those additional hours worked

• Where concern raised that breaks missed on at least 25% of occasions across a 4/52 reference period, and concern validated, GSWH will levy a fine at the rate of twice the relevant hourly rate for the time in which the break was not taken

• To ensure that no further breaches occur, a work schedule review will be required

Educational Exception Reporting

• Problems completing Workplace Based Assessments (WPBAs)

• Inadequate clinical exposure to achieve learning outcomes

• Inadequate frequency and/or quality of clinical supervision

• Lack of feedback

• Cancelled educational events

• Inability to attend educational events

Reporting breaches/Exceptions Reports/Fines/Rota Gaps by guardian

• Reporting internally (Trust Executive) and externally (HEE) provides assurance to junior doctors, and gives the Board information to act upon • Trust Executive and Local Negotiating Committee (LNC) will receive a quarterly report from the guardian to include data on rota gaps. The guardian can also submit an exceptional report to Board if issues remain unresolved • The guardian may identify issues which cannot be resolved at a local level, and should inform the Board of such issues • The Board will produce a consolidated annual report on rota gaps and the plan for improvement, and is responsible for providing this to external national bodies.

Your clinical (or educational) supervisor

reviews and discusses the reasons with you

WITHIN 7 DAYS OF RECEIVING THE REPORT

Safe Working Exception (Hours and Breaks)

Responsibility of clinical supervisor

Sent to clinical (or educational) supervisor

Your clinical (or educational) supervisor

reviews and discusses the reasons with you

WITHIN 7 DAYS OF RECEIVING THE REPORT

Sent to clinical supervisor (or educational) supervisor

Training and Education Exception

Responsibility of clinical supervisor

The Guardian Knot

Challenges

• Training of Educational Supervisors about role and

responsibilities

• Culture of openness in reporting by Junior Doctors

• Review of training posts where persistent breaches of

working hours

• Balancing role as champion against objectivity

• Ensuring that safe working hours also apply to day-time

routine work

• Timely actioning of Exception Reports by CS/ES