Exception reporting two years on

Exception reports were introduced in England in 2016 as part of the new terms and conditions of service for doctors and dentists in training. They aim to give trainees a real time tool to report times when they work beyond their rostered hours. Dr Christopher Kirwan, the guardian of safe working hours at Barts Health NHS Trust, tells us what lessons have been learnt so far from this initiative.

Two years on, exception reporting at Barts Health (a large trust in London with 1044 trainee posts) has given valuable insight into working practices of trainees and the problems they face. They have also helped to direct improvements in working conditions and practices to support safe working.

  • Over the last year at Barts Health exception reports have predominantly come from foundation year one doctors (60%) despite them only being 11% of the trainee workforce.
  • A further 21% have come from foundation year two doctors (again, 11% of the trainee workforce).
  • 16% and 3% have come from core training and specialist training grades respectively (28% and 45% of the trainee work force).
  • Some trainees submitted multiple reports but depending on grade, anywhere between 1% and 20% of individual trainees submitted a report in any given quarter.

We identified a number of different typologies and interesting findings in the exception reports submitted by our trainees.

  • Trainees are very busy. Foundation year one trainees in particular need support and guidance to prepare them for the complexities of doing their job in a hospital setting. It is no coincidence that spikes in exception reporting are seen just after each rotational change over.
  • Failures of the rota pattern have always led to work schedule reviews when the reality of tight shift times and the nature of handovers have been miscalculated. These have tended to be very quickly resolved (usually in under 72 hours) by the team once they have realised the problem.
  • 'Service support' encompasses a broad range of issues, such as finding specific kit, late arrival of blood test results and technical/IT problems. Many of these issues can be easily fixed or improved which can make a huge difference to the morale of a trainee at work. Doctors find it especially annoying when simple things are a struggle.
  • Rota gaps and having to provide cover for sick colleagues are both inevitable. But it's key that these are recorded as a measure of both staffing issues within the NHS and the inflexibility of the working patterns and rota rules.
  • Finally, it's key that consultants and other senior clinicians ensure they are mindful that decisions they make may have a much bigger impact on trainee working patterns than they realise (e.g. starting a ward round at 5pm instead of 2pm). Thankfully there is evidence that this message is beginning to get across.

Exception reporting is a positive development from the new junior doctors' contract that has, in many instances, led to rota errors being corrected quickly. It has also highlighted a number of problems that can easily be corrected to improve working conditions for trainees. In a recent internal survey (July 2018) 68% of trainees felt exception reporting was as good as or better than previous systems for reporting working hours problems. Yet they also were clear that other changes in the contract had potentially made many things worse. To continue to support safe working more innovative workforce planning is needed to limit the impact of staff shortages.