Rota Design for 2009 - North Western Deanery

WORKING TIME DIRECTIVE 2009PUBLICATIONS SERIESRota Designfor 2009

Author biographiesDr Masood Ahmed MBBSMasood Ahmed has a long standing love affair with theNew Deal and Working Time Directive (WTD). Hegraduated from Charing Cross and Westminster MedicalSchool in 1997 and after moving to the West Midlandshe became involved in medical politics. In 2003 hestarted as project manager, then associate medicaldirector to the West Midlands Deanery Action Team.Masood has since held positions as deputy chair of theBritish Medical Association’s (BMA) junior doctorscommittee (JDC) and chair of the JDC negotiating subcommittee. He led the team that negotiated the currentST pay scales and national banding appeals advice.Masood is currently completing his training in generalpractice and is proud father to seven children, soworkforce planning is a concept he takes seriously bothin the workplace and at home and rota design is neverfar from his heart.Dr Yasmin Ahmed-Little MBChB,MA (Merit)NHS North West/North Western Deanery/MerseyDeaneryYasmin Ahmed-Little is currently leading a team of 7junior doctors on an ambitious project to implementWTD targets one year ahead, by August 2008, acrossNHS North West, NW & Mersey Deaneries. Shegraduated from Manchester Medical School in June2000 and joined the North West Regional Action Teamshortly after completing her house-jobs. She has sinceled on issues relating to junior doctors’ hours andworking lives, implementing New Deal and WTD 2004,and now working towards full WTD 48hr compliance.Yasmin is a member of the Working Time DirectiveProgramme Delivery Board and was recently elected tothe BAMMbino Board. She has completed a Masters inHealth Services Management, will commence as CMOclinical adviser to NHS North West in September 2008and is due to start her ST1 in Public Health in August2009.

Contents page1. Introduction 21. Setting the scene 22. Importance of goodrota design 33. Caveats/assumptions 42. Basic New Deal and WTD Revision 6Financial Implications 73. Rota Design Life Cycle 8Seven steps to success 91. Problem Identification 92. Feasibility study 103. Analysis 104. Design 145. Implementation 156. Evaluation 157. Review 164. Good practice guidance 18Handover 18Bleep policies 18Exception reporting 18Rota information at induction 18Trust WTD policies 20Natural break policy 20Approval to change band proforma 20Approval to change band/work pattern 22Agreement of trainees to proposed changein work pattern 24Agreement of improving junior doctors’ workinglives team to proposed change in work pattern 25Educational approval for proposed changein work pattern 26Improving junior doctors’ working lives team– Trust evidence to support stage 3 277. Additional Advice 348. Support, Evidence and guidance alreadyavailable 381. Royal college guidance 382. BMA 383. NHS 384. ‘Cell Of 11’ 38Normal working day 39Conclusion 419. AppendicesAppendix A – Software tools available tosupport rota design 42Appendix B – Example Bleep Policies 43Appendix C – Sample WTD policy 52Appendix D – Example natural break policy 60Appendix E – Banding Appeal Guidance 62Appendix F – Further information 6510. References 665. Pitfalls to avoid 28Rotas monitoring into higher pay bands 28On call rotas 2824 hour partial shifts 28Management of Leave 29Use Of Junior Doctor Rota Masters 29Monitoring of trainees working away fromthe main trust site 296. Banding Appeals 30Official guidance 30At Banding appeal 321

1. Introduction1. Setting the sceneThe implementation of Working Time Directive (WTD) inAugust 2004 presented the first challenge to juniordoctors hours in meeting the UK wide legislation thathas been in place since 1998 . This was the first step ina staged introduction of WTD. August 2009 sees thefull implementation of the rules and regulations thatwill bring junior doctors’ hours in line with the rest ofthe UK.WTD 1998UK wide implementationof 48 hour working weekexcluding junior doctorsand deep sea divers butapplied to most NHS staffPlanning for robustand sustainablesolutions for August2009 requires carefulconsideration ofservice delivery,education andtraining andresources/hoursavailable. These three aspects of the ‘WTD triad ofpatient care’ provide the foundation for success.ServicedeliveryPatient careFig 1 ‘WTD triad of patient care’EducationandtrainingReduction in working hoursIt may be easy to construct legally viable rotascompliant with New Deal and WTD. However it’s farmore challenging to create compliant rotas which alsomeet service delivery and educational needs. In manyinstances, previous 2004 solutions have beenunsustainable and had a subsequent detrimental effectas they eroded training opportunities and loweredmorale. A more considered approach is essential for2009 and long term success.2This guide is aimed at equipping key stakeholders witha range of tips and tools to prepare them in the run upto August 2009 and the implementation of the 48 hourworking week. There are no set rules, meaning whatworks for one trust may not work for another. Howeverthis guide can provide a framework for a systematicapproach to the problems that may be faced within anorganisation as it prepares for WTD.Early planning is key and good rota design is a majorcontributory factor. Poor rota design threatens training,service delivery, work/life balance, morale and ultimatelypatient care.Good rota design underpins all sustainableWTD 09 plans.

2. Importance of goodrota designi. The benefits of good rota designIt’s recognised that WTD compliance and reduction ofjunior doctors’ hours cannot be achieved purely throughrota redesignHowever good rota design can lead to:● More efficient use of human resource, maximisingservice delivery● More efficient use of financial resource● Maximising education and training potential,safeguarding the quality of medical workforce andfuture consultants● Minimising fatigue for a happier, more productiveworkforce● Minimising the risk of banding appeals and referralsto the Health and Safety Executive (HSE).ii. Penalties of poor rota design– impact upon service delivery, education andtrainingThe greatest impactof August 2004 WTDimplementation wasupon daytimepresence of juniormedical staff.Traditional on callrotas disappeared as a consequence of the SiMAP andJaeger rulings and the need to provide continuedresident 24/7 cover in most specialties led towidespread changes in the way teams were structuredand care delivered.Trusts relied on theimplementation of fullshift work patterns tomeet WTDrequirements andservice delivery needs,however thecomponents of theThe SiMAP judgementconfirmed all time spenton work premisescounted as ‘work’.The Jaegar judgementreinforced SiMAP andconfirmed compensatoryrest must be issuedimmediately.‘WTD triad of patient care’ were given limitedconsideration and subsequently many junior doctorsraised training issues. It was at the SpR grade that theimpact was most significant. An increase in ‘Hutton’numbers was part of the solution, but this led todifficulties with longer term workforce planning. A‘Hutton’ bulge is anticipated as these trainees attainCCT in the near future and there is no correspondingincrease in the consultant workforce.3This approachhighlighted thatthrowing additionaldoctors into a rotamay not always bethe best solution.Poor rota planningmeant some juniorswere working shifts,What was a Huttonnumber?Additional locally fundedWTD SpRs created tosupport 2004 WTDimplementationbeing away from wards and clinics for a week at a timeas they worked night shifts and also receivedcompensatory time off. This had an obvious impactupon service delivery but also education and training, asa large proportion of formal and supervised trainingopportunities occurs during the daytime (see cell of 11section).

3. Caveats/assumptionsi. WTD theoretical hours and incorporation of PCThe rules for calculating average working hours underNew Deal guidelines and WTD differ. New Dealrequirements include the provision of prospective cover(pc) ie an allowance within the hours to accommodatethe fact that the junior doctors are required to arrangeappropriate cover in advance of taking leave and swapany out of hours shifts, working their allocation beforeor after their holiday. There are several ways to calculateprospective cover but the two most common methodscan be found as follows:● Department of Health (DH) guidance on workingpatterns for junior doctors, November 2002● BMA junior doctors’ handbook 2005/6.Hours calculations under WTD take leave into accountbut use a different methodology. The calculationapplicable from the European Union (EU) directive isgiven opposite.Most organisations will use New Deal’s hourcalculations as an estimation of WTD hours of work. Inreality this should be a reasonably safe approach as theinclusion of pc hours should prevent any underestimation,however this should always be doublechecked as exceptions can arise due to the differingdefinitions of work and rest between WTD and NewDeal. For example some Band 1 rotas are notautomatically WTD compliant. Doctors may have beenmonitored to demonstrate less than 48 hours of actualwork (due to the deduction of rest from the hours ofduty) whilst resident for more than 48 hours thereforenot meeting WTD 2009 requirements. Another exampleis where an individual junior doctor starts and endstheir reference period working night shifts. This cantake their average working hours over the WTDreference period of 26 weeks above 48 hours. However,under New Deal calculations the hours of work areaveraged over a different reference period of the rotacycle and this may show the same individual as workingless than 48 hours. It’s important to remain conscious ofpossible exceptions. Calculations conducted by theWorkforce Review Team suggest a possible 10% errorwhen using New Deal pay bands as a proxy for WTDcompliance.(6) For the purposes of this regulation, a worker'saverage working time for each seven days duringa reference period shall be determined accordingto the formula:A + BCWhere:● A is the aggregate number of hours comprisedin the worker's working time during the courseof the reference period● B is the aggregate number of hours comprisedin their working time during the course of theperiod beginning immediately after the end ofthe reference period and ending when thenumber of days in that subsequent period onwhich they have worked equals the number ofexcluded days during the reference period● C is the number of weeks in the referenceperiod.(7) In paragraph (6), ‘excluded days’ means dayscomprised in:(a) Any period of annual leave taken by theworker in excess of his entitlement underregulation 13(b) Any period of sick leave taken by theworker(c) Any period of maternity leave taken bythe worker(d) Any period in respect of which the limitspecified in paragraph (1) did not apply inrelation to the worker by virtue ofregulation 5.4

2. Basic New Deal andWTD RevisionNew Deal vs WTD: Who wins?This area causes a great deal of confusion. It’s importantto appreciate the difference but understand that bothsets of requirements must be fully met.Requirement for complianceNew DealContractual obligation(junior doctors’ contract2000)WTDLaw(health and safety legislation)Penalty for non complianceFinancial – band 3 paymentsIntervention by health andsafety executive,improvement notices, possiblefines to trust and legal actionagainst CEO. Breach of theCorporate Manslaughter Act2007. Possible litigationfollowing clinical errors bynon-compliant doctorsNew Deal requirements were agreed in 1991 and aformal requirement for compliance incorporated in thenational junior doctors’ contract since 2000 . Alltrainees are required to be fully New Deal compliantand since August 2003 any failure to do so is a breachof contract and attracts a financial penalty of Band 3payments = 100% supplement of the juniors’ basicsalary.A typical eight doctor rota at Band 1A monitoring asnon compliant (Band 3) will result in the trust havingto pay over £140,000 per annum in additionalsalaries, with further potential financial liabilitiesresulting from pay protection of up to £85,000[calculated using PC(MD) 7/2007].WTD requirements were introduced for all NHS staff in1998 1 however junior doctors were exempt. Theregulations were extended to include stagedintroduction of WTD for junior doctors as follows:DeadlineAugust 2004August 2007August 2009Maximum average working week58 hours56 hours48 hoursWTD is health and safety legislation and as such fallswithin the remit of the HSE to respond to anycomplaints relating to non compliance. WTD is notlinked to pay but is intended to safeguard hours ofwork and mandatory daily and weekly restrequirements.6

Financial ImplicationsThe current New Deal pay band supplements are as follows:Pay Band% supplement of basic salary3 1002A 802B 501A 501B 401C 207

3. Rota Design Life CycleRota design has long provided a challenge to thoseresponsible for rota management. Whilst many possessthe skills and the knowledge for effective rota designthere is often a framework missing that encompassesthe different contributions made for successful rotadesign, implementation and maintenance. The problemis that there are no right answers, what works at onetrust may not work at another. However, underpinningevery problem are the principals that need to befollowed for our goals to be met.This Life Cycle is a concept designed to provide asystematic approach to rota design. It will facilitatethe development and establishment of rotas bylooking at the foundations needed for success, aswell as providing information that can be reflectedupon at a later date as the workforce evolves in anever changing NHS.7. ReviewProcess BoxStage 36. Evaluation1. ProblemidentificationRota Life Cycle –The seven steps tosuccess2. Feasibilitystudy3. Analysis5. ImplementationProcess BoxStage, 1a, 1b, 1c4. DesignTesting8

Seven steps to success1. Problem identification2. Feasibility study3. Analysis4. Design and testing5. Implementation6. Evaluation7. Review1. Problem IdentificationThe starting point for any rota redesign should alwaysbe the existing rota. While it‘s easy to focus on whatthe problems are, it’s usually more productive to beginwith the aspects that are successful. It’s vital that thestrengths of the current rota are considered andpossibly incorporated in any rota redesign and toestablish the reasons for their success. Only when youhave confirmed what is successful should you moveonto what the problems may be. Again, carefulconsideration must be given as to why the rota doesnot work – is it because of the lack of numbers orperhaps issues regarding policy for example bleeppolicy, or referral policy? Are there multi disciplinarylimitations that prevent effective teamwork and crosscover? Are there physical barriers such as split sites orallied services within a hospital which are located at adistance from each other? Are there difficulties withconsultant numbers or senior supervision? These arejust some of the issues which may hinder a rota fromrunning at its peak potential.For each stage a systematic approach is advisable. Thiscan be done using the ‘5W’s’ method.What Why Who HoW WhenIdentify theproblemsWhy is it a problem?Who should beinvolved?How can theproblem be solved?When are youaiming to havethe answers?What impact doesthis have on otheraspects of theservice?Which stakeholderscan offer solutions?Is there goodpractice elsewhere?Who is directlyaffected?Suggestions fromstakeholdersResources required,internal vs externalexpertiseWorked exampleShift over runsPotential WTD noncomplianceJunior doctors,consultants, nursingstaff, directoratemanagersTo be completed atanalysis stage ofthe cycleBeforecommencingdesign stagePotential New Dealnon compliance9

2. Feasibility studyAfter identifying the major problems, the next stage isto investigate the feasibility for designing a new rota.The following must be considered:●●●●●Is there support within the organisation for change?Has time and human resource been allocated tofocus on the project?Has funding been made available if extra resourcesare required?Are the software tools available for rotadevelopment? (see Appendix 1)Does the current team possess the skills to redesignthe rota?By identifying these factors at an early stage it’s possibleto determine what limitations may apply and thisinformation can be used to formulate proposals forresources that will ensure the success of the project.Some organisations may not be able to provideadditional resources immediately but by identifyingthese issues they are equipped with evidence to informa business case.3. AnalysisThis is the fact finding stage of the cycle, during whichit will be possible to identify the needs of the service inaddition to the education and training needs of thejunior doctors. Also at this stage the rota designers willhave the opportunity to identify other problems, as wellas put forward potential solutions ie populate the‘HoW’ column (see problem identification stage).This collection of knowledge can be carried out in anumber of ways depending on the resources availableand time pressures. The team may decide to usequestionnaires with focussed questions relating to theproblems already identified and with open-commentboxes to give interviewees the opportunity to highlightother issues of concern. A more time consuming, but indepth analysis, can occur if resources are available forinterviewing key staff including consultants, nurses,ward administrators and junior doctors.By collating this information it should become possibleto determine a list of user requirements wherebyessential skills, processes and policies are identified.Much of this information will be subjective, but byacting on locally identified problems staff will haveownership of service reconfiguration and this is morelikely to lead to long term success.Pulling together all the facts will result in a rotaspecification that can then be used as a template forthe rota design. For example:Rota Specification – FY1 General Medicine, Trust X Essential Desirable10 doctor rota ✓Normal working day 8:30am-5pm✓Some exposure to out of hours working✓Some exposure to weekend workingSome exposure to night shift workingProspective cover✓Handover✓Band 1 rota✓Band 1B rotaProtected teaching Thursday afternoons✓Clinics Monday and Wednesday morningConsultant ward round✓Exposure to emergency admissions✓✓✓✓✓10

Rota Design Life CycleThis exercise may include the use of the workloadanalysis grid as follows:Workload analysis gridi) Blank Workload Analysis Grid To be CompletedBy Relevant StakeholdersAsk key staff to complete the blank grid using a trafficlight system to identify perceived workload pressures forthe specialty and grade in question at different times ofthe day. The use of four hour slots will assist withmanagement of natural breaks but the grid can beadjusted as needed.Mon Tues Weds Thurs Fri Sat Sun1 9am–1pm2 1pm–5pm3 5pm–9pm4 9pm–1am5 1am–5am6 5am–9amKey:Workload Busy Moderate Quietii) Worked example – data collected relating to subjective assessments bydifferent stakeholder of F1 workload in general medicine at trust XCONSULTANT Mon Tues Weds Thurs Fri Sat Sun1 9am–1pm2 1pm–5pm3 5pm–9pm4 9pm–1am5 1am–5am6 5am–9am+11

F1s Mon Tues Weds Thurs Fri Sat Sun1 9am–1pm2 1pm–5pm3 5pm–9pm4 9pm–1am5 1am–5am6 5am–9am+WARD NURSESMon Tues Weds Thurs Fri Sat Sun1 9am–1pm2 1pm–5pm3 5pm–9pm4 9pm–1am5 1am–5am6 5am–9amA&E/MAU Mon Tues Weds Thurs Fri Sat Sun+1 9am–1pm2 1pm–5pm3 5pm–9pm4 9pm–1am5 1am–5am6 5am–9am12

Rota Design Life Cycleiii) Worked example: AnalysisMethodology1. What does the department need and whenAnalysis by dayMondays are often busy following weekend on call asinvestigations are pending and most support servicesresume activityThere is a lull in activity mid week after 5pmAnalysis by time slotF1 presence is crucial during 9am-5pm during the weekAt weekends morning activity (9am-1pm) for F1s is lower2. Possible sources of data for analysisQuantitativeHAN data/iBleep dataQualitative data● Completed workload analysis grids● Interviews● QuestionnairesResults – this is achieved by pulling all the available data together to formulate conclusionsDataEvidence available at Trust AQualitative Consultants Believe F1s presence is needed at all times but mainly until midnightF1sWard nursingstaffA&E/MAU staffBelieve best emergency exposure is from midday to midnight mostdays, and elective exposure 9am-5pmNeed F1 presence before lunch on weekdays, other staff can assist onweekend mornings eg phlebotomists, assistant practitionersNeed F1 presence after lunch through to 9pm most days, with coverlater in to the night on Fridays and SaturdaysQuantitative HAN data Clear need for significant F1 presence Monday-Friday 9am-5pmFriday-Monday twilight support is essentialTuesday-Thursday twilights are clearly quieterFriday and Saturday nights are clearly busy with a lull in activitypost midnightWeekend mornings are busy on the wards but quiet in admissionsFinal workload analysis grid – this provides a template upon which to base the rota designMon Tues Weds Thurs Fri Sat Sun1 9am–1pm2 1pm–5pm3 5pm–9pm4 9pm–1am5 1am–5am6 5am–9am13

4. Design“There cannot be a ‘one size fits all’ solution, asindividual situations will differ in many ways” (RotaDesign Made Easy, BMA) 9 .When all the strands of the previous stages have beenpulled together you should have a clear rotaspecification upon which to base your design.Depending on the expertise available you can approachrota design in three ways:1. Start from scratch to give a bespoke, best-fit solution2. Modify existing local templates3. Utilise example templates from the NWPdatabase/other external sources.There is extensive material available to provide furthersupport for this stage 9.The worked example used earlier for the F1 rota inGeneral Medicine at Trust X could produce thefollowing example rota template, based on the datagathered during the analysis stage.12345678910Mon Tues Weds Thurs Fri Sat SunC: Long day09:00 – 21:30Stnd day09:00 – 17:00Stnd day09:00 – 17:00E18:00 – 21:00Stnd day09:00 – 17:00Stnd day09:00 – 17:00Stnd day08:00 – 17:00Stnd day09:00 – 17:00Stnd day09:00 – 17:00Stnd day09:00 – 17:00C: Long day09:00 – 21:30Stnd day09:00 – 17:00Stnd day09:00 – 17:00Stnd day09:00 – 17:00Stnd day09:00 – 17:00Stnd day09:00 – 17:00Stnd day08:00 – 17:00Stnd day09:00 – 17:00Stnd day09:00 – 17:00Stnd day09:00 – 17:00C: Long day09:00 – 21:30Stnd day09:00 – 17:00Stnd day09:00 – 17:00Stnd day09:00 – 17:00Stnd day09:00 – 17:00Stnd day09:00 – 17:00Stnd day08:00 – 17:00Stnd day09:00 – 17:00Stnd day09:00 – 17:00Stnd day09:00 – 17:00C: Long day09:00 – 21:30Stnd day09:00 – 17:00Stnd day09:00 – 17:00Stnd day09:00 – 17:00Stnd day09:00 – 17:00Stnd day09:00 – 17:00Stnd day08:00 – 17:00Stnd day09:00 – 17:00Stnd day09:00 – 17:00Stnd day09:00 – 17:00C: Long day09:00 – 21:30Stnd day09:00 – 17:00B09:00 – 21:30Stnd day09:00 – 17:00Stnd day09:00 – 17:00C: Long day09:00 – 21:30Stnd day08:00 – 17:00Stnd day09:00 – 17:00Stnd day09:00 – 17:00Stnd day09:00 – 17:00B16:00 – 00:00A09:00 – 17:00B13:00 – 21:00A00:00 – 17:00TestingWith each rota design, software tools can supportvalidity testing however the following areas should beconsidered and some require human judgement.Process Box●●●●●Is it legal (WTD compliant)?Is it affordable (New Deal compliant and withinexpected pay band)?Is it realistic?Is it socially acceptable (start and end times,weekend frequency, ‘Improving Working Lives’)?Is it educationally acceptable?Complete stage 1a, 1b, 1c ofre banding proforma14

Rota Design Life Cycle5. ImplementationOnly after the initial paperwork has been signed off andapproved by the action team at the Strategic HealthAuthority, or successor body, can plans be made forimplementation.An appropriate implementation date should be agreedin partnership with all key stakeholders. Implementationprior to August 2009 will allow full evaluation of therota with time to make any modifications required toensure compliance. Implementation at handover inAugust 2009 will require, where appropriate, stage 2provisional banding approval prospectively, prior torecruitment and implementation.At this stage it is also advisable to agree a date formonitoring post-implementation. Please note if stage 2provisional banding has been agreed, monitoring musttake place within six weeks of implementation of therota, otherwise the provisional rebanding is invalidated.Process BoxConsider whether stage 2provisional approval of the rebanding proforma is required6. EvaluationFollowing implementation a rota must be monitored sothat the rebanding process can be completed at stage3. Results from all monitoring exercises should bepublished within 15 working days of receipt of a validreturn 5 . In addition to this the six monthly monitoringexercise provides a useful evaluation of the sustainabilityof the rota. But monitoring should not be the only formof feedback if the rota cycle is to be used effectively forthe evolution of rotas. Feedback may be obtainedthrough questionnaires, exception reporting and byregular follow up with those involved with the rotas (forexample at mess meetings, teaching sessions or multidisciplinarymeetings).Process BoxSubmit monitoring results toaction team (or successor body)for completion of stage 3 of there banding proformaThere are four criteria which must be considered fordetailed evaluation:Suitability● Does the new rota provide anappropriate solution?● Is the WTD triad of patientcare achieved?● Does the rota meet the rotaspecifications?Effectiveness● Does the rota work in reality?● Does it meet WTD requirements?● Is it compliant with the New Deal?● Are there any problems?ServicedeliveryPatient careUsability● Is the rota easy to follow?● Is it confusing for doctors/ward staff?● Is it flexible enough for leave and sickness?● Is there a work/life balance?● Is there a training/service balance?Maintainability● Is the rota robust in the long term?● can it cope with seasonal pressures/leave?● Are there any limitations?● Are modifications required?EducationandtrainingReduction in working hoursBy carrying out a detailed evaluation followingimplementation, it’s possible to highlight potential problemsand be proactive with rota review rather than wait forproblems that may eventually impact on patient care,service delivery or training needs.15

7. ReviewThe three possible outcomes at this stage are:1. Success. Congratulations! The rota is compliant andstable2. Needs slight tweaking and re monitoring3. Significant problems, may be non compliant, back tostage 1 of the cycle.By bringing together all the information frommonitoring and evaluation it’s possible to report on anyissues or limitations of the new rota, and to see howthese might compare with the original objectives andspecification. The audit trail provided by the Rota LifeCycle will evidence decisions taken regarding any issueshighlighted earlier in this process, allowing any furthernecessary modifications to follow an informed andtransparent process. If the problems are new then thecycle can be repeated by returning to the problemidentification or analysis stage and using the 5Ws.SUMMARYSeven steps to success: Rota Life Cycle1. Problem ID, 2. Feasibility, 3. Analysis, 4. Design,5.Implementation, 6. Evaluation, 7. Review‘5W’s’What, Why, Who, HoW, WhenTriad of Patient CareService, Training, HoursOne goalPatient care16

17Rota Design Life Cycle

4. Good Practice GuidanceHandoverMost rotas will require a minimum handover of 15minutes, usually 30 minutes and in some instances evenlonger. Handover is critical for safe transfer of patientinformation to deliver continuity of care and goodquality patient management. In 2004 the BMA inconjunction with NPSA and many other stakeholderscreated a detailed and useful guide to handover 11 .Bleep policiesThese are an effective way of managing overall juniordoctor workload, minimising/eliminating the number ofinappropriate referrals made freeing up the doctors totackle appropriate areas of clinical need. Bleep policiesprovide an agreed framework for nursing staff to followwhen assessing the need to bleep a doctor. In someinstances for example it may be more appropriate tocontact a nurse practitioner in the first instance to takebloods or triage a stable patient. National Hospital atNight data also clearly demonstrates the reduction ofinappropriate referrals made when a bleep policy is inplace and that where all overnight calls are filtered by asenior nurse, no inappropriate calls at all are made tojunior doctors.807060504030201000%Bleeps at night% jobs that could be undertaken by anotherWith bleeppolicyprofessionalAll callsfiltered bysenior nurseNo bleeppolicyException reportingSuccessful implementation is often seen at sites where atrue partnership approach between juniors and the trusthas been taken when implementing new workingpatterns. In order to foster a cooperative approach it’sworth considering a system of exception reporting forpossible WTD and New Deal infringements on juniordoctor rotas. The health and safety of trainees is betterprotected in this manner and encourages ongoingservice improvement.This requirement can be included within trust ordirectorate policies, giving clear rules for and lines ofreporting. In addition to this it is beneficial to issuethese guidelines at induction (see section d).Rota information at inductionIt is highly recommended that rota template details areissued to all junior doctors at induction with a record ofreceipt documented. It’s important that HR, thedirectorates, consultants and ward staff all know theagreed work pattern. It‘s often reported at bandingappeal that the juniors were never aware that the rotaincluded half days off etc. Issuing the master templateat induction would limit rotas falling in to Band 3 as aconsequence of poor communication. Furthermore thisopportunity can be used to request juniors report anyunauthorised changes to their working hours as soon asthey arise (see above, section c re exception reporting).The following is an example template used to providethis information at induction:Some examples of bleep policies currently in operationare attached in Appendix B.18

NHS North WestEWTD MWDTNHS trust XAgreed rota template for circulation to all junior doctors at induction/start of new postSite AGeneral medicineF2 and junior ST rota template as at 1st August 2008Working pattern – full shift rotaRest requirement – natural breaks (min 30 mins continuous rest after approx four hours’ duty)New Deal pay band – Band 1B12345678910MonN21:00 – 09:30Stnd Day09:00 – 17:00Stnd Day09:00 – 17:00Zero HoursD: Long Day09:00 – 21:30Stnd Day09:00 – 17:00Stnd Day09:00 – 17:00Stnd Day09:00 – 17:00Stnd Day09:00 – 17:00Stnd Day09:00 – 17:00TuesN21:00 – 09:30Stnd Day09:00 – 17:00Stnd Day09:00 – 17:00Zero HoursStnd Day09:00 – 17:00D: Long Day09:00 – 21:30Stnd Day09:00 – 17:00Stnd Day09:00 – 17:00Stnd Day09:00 – 17:00Stnd Day09:00 – 17:00WedN21:00 – 09:30Stnd Day09:00 – 17:00Stnd Day09:00 – 17:00Stnd Day09:00 – 17:00Stnd Day09:00 – 17:00Stnd Day09:00 – 17:00D: Long Day09:00 – 21:30Stnd Day09:00 – 17:00Stnd Day09:00 – 17:00Stnd Day09:00 – 17:00ThurN21:00 – 09:30Stnd Day09:00 – 17:00Stnd Day09:00 – 17:00Stnd Day09:00 – 17:00Stnd Day09:00 – 17:00Stnd Day09:00 – 17:00Stnd Day09:00 – 17:00D: Long Day09:00 – 21:30Stnd Day09:00 – 17:00Stnd Day09:00 – 17:00FriZero HoursStnd Day09:00 – 17:00N21:00 – 09:30Stnd Day09:00 – 17:00Stnd Day09:00 – 17:00Stnd Day09:00 – 17:00Stnd Day09:00 – 17:00Stnd Day09:00 – 17:00D: Long Day09:00 – 21:30Stnd Day09:00 – 17:00SatN21:00 – 09:30D: Long Day09:00 – 21:30SunN21:00 – 09:30D: Long Day09:00 – 21:30I can confirm that I have received a copy of the rota template above and understand that this is the currentworking pattern I should be following.I also agree to exception reporting ie I will alert the medical staffing department at trust X if I find I am regularlyworking hours different to those given above, eg if I am not able to attend formal teaching sessions, not receivinghalf days/full days off duty as specified within the rota template, working regular early starts and/or late finishes orI am not meeting the rest breaks as detailed above etc.Name:Position:Date:Signature:19

Trust WTD policiesThere are many areas in the interpretation of WTD rulesthat have not yet been tested legally, for examplearound the provision of compensatory rest. Manyorganisations have therefore agreed trust policiesaround junior doctors’ hours, monitoring, New Deal andWTD. The following areas may be included:●●A trust may require staff to monitor their workinghours twice a year in response to the request of theHR department (not just junior doctors in training)Clarity around the trust’s position on compensatoryrest including whether this should be taken in paidor unpaid time.An example of such a policy has been included inAppendix C. This is by no means exhaustive nor does itcover all possible interpretations, it merely offers anexample of one view point. Trusts are advised to seektheir own legal advice.Natural break policyWhere organisations have struggled to ensure naturalbreaks are taken by all junior doctors they haveimplemented policies to highlight the joint responsibilityin achieving this. This can reassure the juniors that trustsdo expect them to be able to take their breaks at alltimes unless they are involved in a life threateningscenario. Equally it can raise awareness amongst nursingstaff who can then manage elective and emergencyworkload around the need for juniors to take breaks.An example of such a policy is attached in Appendix D.Approval to change bandproformaWhen implementing changes to any junior doctorsworking patterns that result in a change in pay band,it’s a requirement to complete the ‘approval to changeband’ process and proforma. This document was agreedbetween the DH and the BMA in April 2002. Theagreement to document these stages in the form of theofficial proforma resulted from great variation inapproach across the country.The completion of this proforma and carefuldocumentation of each stage is critical. If a trust ischallenged on the pay band of a rota and they do notpossess this documentation to prove the pay band, theyare left in a difficult position at banding appeal and willinevitably lose irrespective of any other worthyarguments they may wish to debate.As such NHS North West have devised a series oftemplates and local version of the ‘approval to changeband’ proforma to provide consistency in approach anddocumentation across the patch and ensure all requiredwritten documentation has been captured. In thefollowing pages the national proforma and copies ofthe NHS North West templates have been provided asan example of good practice.20

Good Practice GuidanceNational ‘Approval to change band’ proforma agreed with the Department of Health & BMA21

Approval to change band/work pattern (NHS North West)Trust:Hospital:Specialty(ies):Numbers of Doctors in Working Arrangement by GradePRHO: SHO: SpR: OtherWorking Pattern:Current Banding: Proposed Banding: Effective Date:Stage 1 Evidence Required Documentation Confirmed Y/N1a.Consult post holders onproposed changes andobtain agreement of themajority participating inthe working arrangements.1b.Submit details of the newworking arrangements tothe action team forinformation and invitedcomment.Approval of majority ofcurrent/incoming postholdersFull details of proposedworking arrangements and/orrota summary (eg fromND2000 software)Template signed by trustjunior doctor representativeconfirming agreement ofmajority of current/incomingpost holdersLetter signed by action teamchair or delegated authorityconfirming theoreticalcompliance of workingarrangements (see below)I confirm that the proposed working arrangements submitted to the action team are theoretically compliantwith the New Deal (To be completed by the action team)Name……………………………………………………………..Signature………………………………………………Designation…………………………………………………………………………………...Date ………………………1c. Obtain agreement fromclinical tutor foreducation purposes.Full details of proposedworking arrangementscomments of action teamLetter signed by dean ordelegated authority confirmingeducational acceptability ofworking arrangementsStage 1 Evidence Required Documentation Confirmed Y/N3. Monitoring of workingpattern and confirmation ofbandingCompleted monitoring returnsfrom 75% of doctors on rotaover full two week periodSummary of monitoring resultsThis signed templateThis Action Team Authorisation at Stage 3 is based on the information supplied by the Trust. Any innacuracies inthe data provided including analysis / interpretation of monitoring data may render this rebanding invalid.Previous banding: Verified New Banding: Effective Date:Trust Signatory(Designation)Rota Signatory(Designation)Action Team Signatory(Designation)Date:Date:Date:22

Trust: Hospital: Specialty(ies):Provisional RebrandingIf exceptionally and because of the impracticality of full implementation of new working arrangements a Trustwishes to offer future posts at an expected banding in advance of actual monitoring, approval must be soughtfrom the Regional Action Team (or its equivalent) in advance of making any such offer. Any offer made in thesecircumstances will be strictly provisional, and must be confirmed by monitoring following the implementation ofnew working arrangements.Stage 2 Evidence Required Documentation Confirmed Y/N2. Submit request forprovisional approval ofworking arrangements toaction teamSigned letter from trust givingreasons for inability to fullymonitor before rebanding.Evidence of full or partialtesting/monitoring of proposedarrangements (See Below)Letter signed by actionteam chair or delegatedauthority authorising anoffer of provisional banding.(See Below)2a. Reasons for inability to fully monitor before rebanding (to be completed by trust)Name……………………………………………………………..Signature………………………………………………Designation……………………………………………………………………………………Date ………………………2b. I confirm authorisation of a provisional new banding (to be completed by action team)Name……………………………………………………………..Signature………………………………………………Designation…………………………………………………………………………………...Date ………………………Current Banding: Provisional New Banding: Implementation Date:Action Team Signatory:Date:23

STAGE 1AAgreement of trainees to proposed change in work patternNHS North WestProposed work pattern for the ................. [insert grade]........ [insert specialty] .................at ................. [insert hospital]12345678910Monday Tuesday Wednesday Thursday Friday Saturday SundayAnticipated band of rota (subject to confirmation):Number of doctors on rotaType of working patternExpected implementation date[Insert band here][Insert number here][Insert work pattern][Insert date here]The aim of this document is to confirm for the purposes of rebranding, including where a work pattern is to bechanged within the same band, that the majority of current or incoming post holders have been consulted aboutthe proposed rota changes and that they find them acceptable.This document will be sent to the Improving Junior Doctors’ Working Lives team at Greater Manchester StrategicHealth Authority as part of our evidence in the rebranding process. The rebranding process is outlined in paragraph22 m of your terms and conditions of service which can be found online at:http://www.nhsemployers.org/docs/terms_conditions_service.pdfDeclarationWe the undersigned represent the majority of the current/future postholders on the above rota. Weagree that this is an acceptable rota and would be willing to work these arrangements at the givenband, provided banding is confirmed through monitoring of the rota within six weeks ofimplementation.Full Name Signature Position Date24

STAGE 1BAgreement of improving junior doctors’ working lives team toproposed change in work patternNHS North WestProposed work pattern for the ................. [insert grade]........ [insert specialty] .................at ................. [insert hospital]12345678910Monday Tuesday Wednesday Thursday Friday Saturday SundayAnticipated band of rota (subject to confirmation):Number of doctors on rotaType of working patternExpected implementation date[Insert band here][Insert number here][Insert work pattern][Insert date here]DeclarationOn behalf of the improving junior doctors’ working lives team at Greater Manchester Strategic HealthAuthority, I hereby confirm that the proposed working arrangements, outlined above, are theoreticallycompliant with the New Deal hours and rest requirements and consistent with Band [insert theoreticalNew Deal band].Signature………………………………………………………Date………………………Name………………………………………………………....Position………………………………………………………..25

STAGE 1cEducational approval for proposed change in work patternNHS North WestProposed work pattern for the ................. [insert grade]........ [insert specialty] .................at ................. [insert hospital]12345678910Monday Tuesday Wednesday Thursday Friday Saturday SundayAnticipated band of rota (subject to confirmation):Number of doctors on rotaType of working patternExpected implementation date[Insert band here][Insert number here][Insert work pattern][Insert date here]Declaration (to be completed by delegated authority of the dean)I confirm that the above rota meets educational and training requirements for junior doctors’ training atthis grade within this specialty.Signature………………………………………………………Date………………………Name………………………………………………………....Position………………………………………………………..26

STAGE 3Improving junior doctors’ working lives team– Trust evidence to support stage 3NHS North WestMonitoring evidence in support of a request for 'approval to change band'TrustSpecialtyGradeMonitoring Attempt 1Monitoring dates% ReturnMonitored bandContracted hoursActual hoursNatural break compliance %Rest compliance (If applicable)Are all other requirements of the New Deal met? Yes NoIf no please give further details/explanation and attach supporting evidence.Please sign and date here on behalf of the trust to confirm you have input and analysed the monitoring data withaccuracy and believe it supports stage 3 of this ‘approval to change band’ requestMonitoring attempt 2Monitoring dates% ReturnMonitored bandContracted hoursActual hoursNatural break compliance %Rest compliance (if applicable)Are all other requirements of the New Deal met? Yes NoIf no please give further details/explanation and attach supporting evidence.Please sign and date here on behalf of the trust to confirm you have input and analysed the monitoring data withaccuracy and believe it supports stage 3 of this ‘approval to change band’ request27

5. Pitfalls to avoidRotas monitoring into higherpay bandsi. New Deal maximum shift durationWhen planning towards WTD compliant rotas it’s criticalto be mindful of New Deal rules that may trip you upleading to Band 3 claims you had not expected. Themost challenging of these are often the rules in relationto the maximum shift duration permissible on differentworking patterns.On call rotasThe 32 hour and 56 hour rule has caused havoc onmany non resident rotas in the surgical sub-specialties inparticular, but also in specialties such as Oncology. AsWTD rules do not stipulate any limits on non residentduty hours, these areas are often overlooked whenplanning WTD compliant rotas.Essentially these rules exist to ensure that after aweekday or weekend on call the junior doctor leaves ontime eg 5pm following a 9am start the preceding day fora weekday on call. This of course presumes a 9am startalthough it’s common practice for surgeons to start theirnormal working day at 8am.The knock on impact of this is that surgical trainees mustfinish early on the day post on call, for example by 4pm,to avoid breeching the 32 hour and 56 hour rule. In realitythis can be difficult to achieve if the trainee is in theatre ora clinic. It’s important to note that this New Deal rule isabsolute, ie it must be adhered to on 100% of occasions,so a single breech can lead to a successful Band 3 claim.Certain provisions may be considered to minimisepossible breeches:●Ensure when a junior doctor is on call they are notrostered for a theatre list or out patient clinic on thefollowing afternoon, which may prevent them fromleaving work on time●●junior doctors for clinics and theatres on their halfdays off, making it impossible for the juniors to leaveearly. It is often far more effective to roster a full dayoff after on-call but this does of course haverepercussions for training and the serviceIf additional time off is rostered on the rota eg halfdays off or full days off, ensure this is communicatedclearly to all the teams within the department,including junior doctors, senior doctors and nursingstaff. If possible incorporate the requirement for thetrainees to be off duty after eg 2pm post on call,within a departmental policyConsider a late start for the first day on call eginstead of coming to work at 8am roster the juniordoctor to start at 10am. This would accommodatefor late finishes the following day up to 6pm,without breeching the 32 hour and 56 hour rule. Itis also easier to comply with a late start, comparedto trying to leave early on the day post on call. Theeducational and service impact of late starts must betaken into account as handover and ward roundscould possibly be missed.24 hour partial shiftsThe maximum possible shift duration on these rotas is24 hours and again this rule is absolute and so must befulfilled on 100% occasions otherwise the rota maydefault to Band 3.This makes handover on such rotas challenging and arange of different solutions are available:●●●Written handoverElectronic handoverCreating an extended shift whereby one traineeeach week comes to work 30 minutes early to takethe handover from the doctor finishing their 24 hourshift before they leave.●Roster in a half day off duty post on call to ensurethe junior doctor has left work before 4pm. In realityhalf days are often poorly communicated by trustsand rarely taken by juniors so proceed with caution.In particular some trusts have continued to rosterWhere resident 24 hour partial shift rotas are inoperation or being considered for use, trusts mustconduct their own local risk assessment in relation tothe WTD compliance of these working patterns.28

ii. Unbanded posts attracting pay bandssupplements on monitoringIncreasing numbers of unbanded posts are beingimplemented at foundation level and above. Rotas witha maximum of 40 hours or less of actual work per weekbetween the hours of 8am to7pm, Monday to Friday arepaid at basic salary with no entitlement to a bandingsupplement. However any early starts, late finishes orshift over runs on such rotas may attract a Band 1Bsupplement of 40%. Therefore clear rules must be put inplace to control the working hours on such rotas and ifit’s suspected that early starts, late finishes or shift overruns may occur from time to time, it’s safer toprospectively roster in half days off on the rota to ensurethe average actual hours of work never exceed 40.This appears to particularly affect particularly foundationposts in General Practice, Psychiatry, Paediatrics andObstetrics and the Pathology rotas in the more seniorgrades.iii. Rotas monitoring in to a different band- Band 2B to 2A; Band 1B to 1AThere are some full shift rotas that are theoreticallyBand 2B but when monitored can fall in to Band 2A.The latter part of the pay band represents the antisocialnature of the rota. Most people tend to judge Band Afrom Band B on the basis of weekend frequency. Whilstthis does form the basis of part of the assessment, theother element of this assessment, known as the ‘out ofhours proportion’, can flip a rota from Band B to BandA on monitoring.For example, full shift rotas running on a 1:7 frequencyfall in to Band 2B on theoretical analysis on the basis onthe weekend frequency being 1 in 3.5, the cut off forBand 2A being 1 in 3 weekends or more frequent.However as there are so few doctors on the rota (7) theout of hours proportion is often very close to the cut offpoint of less than a third. When leave is factored in andthese rotas are monitored they will often demonstrate anout of hours proportion of greater than a third andtherefore monitor in to Band 2A. Adding more days offon these rotas does not help, in fact it further exacerbatesthe problem! If planning a Band 2B full shift rota it issafer to work with rota sizes of 8 upwards.When planning for WTD compliance it’s important tonote a similar situation arises with Band 1B full shiftrotas monitoring in to Band 1A. A 1:9 full shift rota willdemonstrate a theoretical pay band of 1B on the basisthat the weekend frequency is 1 in 4.5, with the cut offto Band 1A being 1 in 4 weekends or more frequent.However on monitoring, once leave is taken in toaccount, a 1:9 rota is likely to monitor in to Band 1A dueto the proportion of out of hours duty. If planning aBand 1B full shift rota it is safer to work with rotasizes of 10 upwards.Management of leaveSome departments manage proposed leave at the startof all rotations. All juniors meet at the start of their postand agree in advance which weeks of leave they wouldlike to take. This ensures everyone is able to take theirfull leave entitlement during their posts and fewer swapsneed to be made later to provide prospective cover. It isalso very helpful to have a central coordinator for leaveand on call swaps.Use of junior doctor rotamastersMany trusts use junior doctor Rota Masters to facilitatethe daily management of rotas. It’s recommended, wheretrusts are planning to use junior doctors as rota masters,to ensure that:●●The junior doctors be issued with a job descriptionoutlining their role and specific responsibilities, includingappropriate lines of referral and additional supportavailable. Any remuneration should also be agreedThey are issued with detailed training on New Deal,junior doctors’ contract, pay banding and WTDrequirements.Monitoring of trainees workingaway from the main trust siteWith Modernising Medical Careers (MMC) there are nowmore trainees working in placements outside the acutetrusts but remaining on acute trust contracts egfoundation posts in psychiatry, general practice,academia and public health. Local agreements must be inplace as to which NSH organisation will be coordinatingthe monitoring of these juniors. This includesdistribution, collection and analysis of monitoring diarycards, in addition to the return of these juniorsmonitoring results twice a year to NHS Employers as partof the ministerial return on junior doctors’ hours of work.Monitoring of all junior doctors twice a year is acontractual obligation. This responsibility is likely to fallupon the employing authority and as such they mustensure monitoring arrangements are in place. Failure tomonitor junior doctors can place those posts into NewDeal non compliance 5 .29

6. Banding AppealsThe following section includes some operational advicefor when trusts decide to take a rota through thebanding appeal process, as per the national terms andconditions of service.Official guidanceExcerpts from all official documents referring to themechanisms of a Banding Appeal have been givenbelow for reference. The DH have issued further practicalguidance attached in Appendix E.AL (MD) 1/01Mechanism For The Allocation Of Banding23. All junior doctors will complete the banding questionnaire. All junior doctors sharing the same rota, shiftor partial shift will be assigned the same banding. Where junior doctors do not have identical duties andresponsibilities as the others on the rota or shift system, however, they should be assessed separately.24. At this first phase, regional improving junior doctors working lives action teams (or equivalent) could beinvolved to help resolve difficulties and to ensure consistency.25. Where agreement is reached on banding, the employer should notify the outcome in writing to thejunior doctors concerned and any relevant consultants and clinical directors. Copies of all documentationshould be available to the regional improving junior doctors working lives action team (or equivalent) whichwill give its opinion in any case where there is a dispute or in other cases at its discretion. Where agreementcannot be reached during the initial phase, the parties will record the issues to be resolved.26. If either party does not accept the regional improving junior doctors working lives action team’s (orequivalent) opinion, there will be a right of appeal – on the grounds of fact – which will be the responsibilityof the employer to operate fairly and transparently. Appeals will be heard by a local trust committee whichshould be convened as soon as possible and trusts are expected to do so while the doctors remain in post.The appeal panel should be constituted of two representatives of the trust nominated by the chief executiveor the medical director (one of whom will chair the panel), a junior doctor representative from the trust(agreed with the junior doctor appellant) conversant with the working patterns involved, a junior doctorfrom a regional list supplied by the UK JDC and an independent external assessor nominated by the regionalimproving junior doctors working lives action team (or equivalent). No member of the panel should havebeen involved in the original banding allocation decision. The decision of the panel is final. The effect of thedecision will be backdated to the date of the change, or to 1 December 2000, whichever is applicable.30

Terms and Conditions of Service, Version 8, July 200722 l. Where either the employing authority or the practitioner rejects the opinion of the regional improvingjunior doctors working lives action team (or equivalent) in any case where there is a dispute regarding theallocation of posts to pay bands or in cases where the regional improving junior doctors working lives actionteam (or equivalent) finds it necessary to intervene, there is a right of appeal:i. Appeals shall be heard by a local committee that shall be convened as soon as possible and employingauthorities shall be expected to do so while the practitioner remains in post.ii. The appeal panel shall be constituted of the following, none of whom shall have been involved in theearlier decision: two representatives of the employing authority nominated by the chief executive or medicaldirector of the employing authority (one of whom shall chair the panel); a representative from the SR, SpR,R, SHO or HO grades from the same employing authority conversant with the working arrangementsapplicable to the case; a representative from a regional list supplied by the BMA’s Junior Doctors Committee;an independent external assessor nominated by the regional improving junior doctors working lives actionteam (or equivalent)iii. Decisions of the appeals panel which confirm the appellant(s) had been underpaid shall lead to thepractitioner(s) receiving appropriate reimbursement backdated to the date of the change, or to 1 December2000, whichever is applicableiv. Decisions of the appeals panel which confirm the trust’s original decision shall lead to the trust receivingappropriate reimbursement backdated to the date of the change, or to 1 December 2000, whichever isapplicable.31

At banding appeal1. There is little point in pursuing a banding appeal ifthe trust is not in possession of a completed copy ofthe ‘Approval to Change Band’ proforma and allsupporting documentation (see section 4g) includingthe following:i. Written confirmation of stage 1a agreementfrom the junior doctorsii. Written confirmation of stage 1b agreementfrom the Action Team or successor bodyconfirming New Deal compliance andappropriate allocation to the proposed pay bandiii. Written confirmation of stage 1c agreementfrom an appropriate delegated authority of thedean confirming educational approvaliv. Written confirmation of stage 2 provisional rebanding approval from the action team orsuccessor body.2. Always ensure that you have obtained anindependent opinion from the regional action teamor successor body prior to going to banding appeal.This opinion may save the time and resourcesinvolved in organising a banding appeal.3. Consider carefully your choice of panel membersrepresenting the chief executive or medical director.Panel members should not have had priorinvolvement in the case but there is no specificstipulation that they must be employees of the trust.In instances where you feel detailed knowledge ofthe New Deal and pay banding structure would beuseful, it’s worth considering nominating an externalrepresentative with New Deal expertise or even aregional action team lead from a different healthauthority. Whilst there may be a cost involved withthis approach this is minimal in comparison to losingyour case on the basis that the trust representativeson the panel were unable to argue against theexpertise of either the JDC or action teamrepresentative. Please note all JDC representatives willhave undergone training to sit on banding appeals.4. Consider whether you require expert representationof your case. Often trusts will lose banding appealsas their case is poorly presented and key argumentsare not made. Also be prepared to cross examinejuniors during the banding appeal to clarify points ofinformation.5. If you wish to dispute the content of monitoringdata it is vital that written evidence is included in thestatement of case submitted by the managementside at least one week before the appeal. Do submitas much evidence as you can gather in support ofany allegations you might wish to make against thevalidity of any data.6. It’s advisable only to take those cases to bandingappeal that you are confident to pursue to anemployment tribunal (ET) should you lose. Mostcases taken forwards by the BMA are lodged for ETeven before the banding appeal is heard.32

33Banding Appeals

7. Additional Advice1. If trusts employ junior doctor rota masters they mustensure that:i) Detailed training is provided on the New Dealand WTD requirements as well as covering areassuch as pay banding and the junior doctors’contractii) The junior doctor is given clear writteninstructions as to what is required of them fromthis post and the support that is available tothem, including appropriate lines of referral, toenable them to deliver on the agreed outcomes.2. Trusts should consider issuing the rota templatesagreed with the SHA at induction to all juniordoctors. Occasionally departmental rotas covering oncall requirements have failed to make it clear thatthe juniors have rostered half days or full days off onthe main rota template agreed with the SHA.Consequently rostered time off is not taken and therota monitor’s into Band 3. As the juniors were neverformally notified of the time off on the rota thesecases usually rule in favour of the juniors. A templateof the type of document that could be issued to alljuniors at induction is included in section 4d.When the juniors are issued with these templates atinduction it’s recommended that trusts keep a signedrecord of delivery and get agreement from all juniorsto exception reporting, ie that the juniors will reportany issues that lead to a deviation from the issuedwork pattern. This will allow trusts to identifyproblems on rotas rather than awaiting routine biannual monitoring data and encourages a proactivepartnership approach in modifying the rota.3. Trusts should implement clear department policiesspecifying the expected start and finish times forjunior doctor rotas within the department for thenormal working day and all out of hours shifts, aswell as the rostered time off on the rota. Anescalation policy in line with exception reportingprocedures should be included and be circulated tojuniors on induction.4. It may be possible to consider alternative residentworking patterns where local trust WTD policiesallow compensatory rest to be given in unpaid timeand New Deal requirements are likely to be met5. Remember that different stakeholders see the rotafrom a different perspective.34

Quantifying the risks - What the managers see:Potential RiskFull ShiftPS24(resident)On call(non-resident)FinancialNew deal non complianceFailure to meet o/n restFinancialNew deal non complianceBreech max shift lengthClinicalgoverance issuesChallenge by HSEChallenge byjuniorsVariableWhat the clinicians see:Potential RiskFull ShiftPS24(resident)On call(non-resident)Loss of educationand trainingopportunitiesLoss of the ‘firm’Poor continuityof careIncreasedworkload forconsultantsChallenge byjuniorsVariable35

Points to consider with other working patternsFor the craft specialties specifically● Must meet New Deal requirements, avoid Band 3● Rest (note this will be paid time)● Shift length.●Full shift working with optimal cell numbers wherethe true OOH workload intensity means no otherworking pattern is possible●●●Local WTD policy regarding compensatory rest● Paid vs unpaid time● Is a planned breech (PS24) legal?Clinical governance issues● Non resident working, is it safe?Different juniors prefer different rotas.●●●Resident PS24 where OOH is quieter but residentcover is requiredNon resident OCR where OOH is very quiet and nonresident working is safeHybrid rotas are complicated but may provide thebalance required for the WTD triad of patient care●Remove overnight cover if it’s demonstrated thatjunior doctors are not required.36

37Additional Advice

8. Support, evidence andguidance already available1. Royal college guidanceIn anticipation of full WTD implementation in 2009many of the Royal Colleges have already issued helpfuladvice. In relation to minimum ‘cell’ sizes on full shiftrotas these colleges have issued specific advice:Royal CollegeMinimum Suggested Cell Size for48 Hour Compliant Full Shift RotaRoyal College of Physicians 6 10Royal College of Anaesthetists 7 8Royal College of Surgeons 8 82. BMAThe BMA published a useful rota design booklet in2004 9 accompanied by guidance on monitoring 10 andhandover 11 .This further clarifies the New Deal rules andpossible rota patterns.3. NHSTo support WTD implementation in 2004 the formerNHS Modernisation Agency issued rota design guidanceto the service 12 .4. ‘Cell Of 11’ 13Studies were undertaken within NHS North West tounderstand the impact of different rota patterns, andmore specifically, full shift working upon normalworking day availability. Anecdotal reports were thatjuniors’ presence was felt to be reduced but there was aneed to quantify this perception. Given most trainingopportunities and service delivery takes place during thedaytime it also seems sensible to try and maximisedaytime availability on 48 hour rotas being planned forWTD compliance.3. Negative impact upon health of working shifts butparticularly night shift working.Minimise exposure to night workingHow?• Increase pool of doctors providing cover overnight– Hospital at Night– Reconfiguration or services– Employ more juniors.• Improve rostering to minimise number of consecutivenight shifts worked by any individual• Structured rest may compensate for sleep loss andpublished literature on coping with shift work.In addition to this there are many sensible reasons as towhy we should be reducing the exposure of individualsto night shift working:1. Performance is poorer overnight, individuals aremore likely to make errors particularly when workingconsecutive night shifts 6 142. Learning potential is poorer overnight 1338

The Normal Working DayThe results from ‘normal working day’ (NWD) analyses on differentworking patterns is given below. These results demonstrated in orderto meet the NWD availability on an eight person full shift rota at 56hours, as per the minimum recommendation by the Academy of RoyalColleges and the BMA in 2004, at least 11 doctors would be requiredon a 48 hour full shift rota.On call vs 56 hour and 48 hour full shift rotas– NWD availability over six monthsNumber ofDoctors/RotaDays available 9-5 in 6months (full shift) 48Days available 9-5 in 6months (full shift) 56Days available 9-5 in 6months (resident on call)64465100785564748010010097183100101174798486100100128387100138688100148789100159090100On Call vs 56 Hour and 48 hour Full Shift Rotas– NWD availability per weekNumber ofDoctors48 hour week56 hour weekOn call rota61.682.513.85782.132.472.853.103.853.8592.743.183.8510112.853.033.253.33.853.85123.183.353.85133.313.383.85143.353.423.85153.453.453.8539

Taking this methodology further the NWD availability on differentresident and non resident working patterns were also compared.Comparison NWD availability across different working patterns- Non resident- As expected NWD increases on patterns with longer permissibleshift lengths.RotatypeNumberof juniorson rota6789101112131456 hour rota 48 hour rotaFull shift (56hrs) Full shift (48hrs) PS16 (non-res) PS24 (non-res) On-call (non-res)Dayspresent9-5 per 6months65.374.080.582.784.485.8Dayspresent9-5 per 6months2.52.83.13.23.23.3Dayspresent9-5 per 6months43.755.464.371.174.078.782.786.087.0Dayspresent9-5 per 6months1.72.12.52.72.83.03.23.33.3Dayspresent9-5 per 6months65.374.077.379.881.883.5Dayspresent9-5 per 6months2.52.83.03.13.13.2Dayspresent9-5 per 6months69.777.783.885.687.088.2Dayspresent9-5 per 6months2.73.03.23.33.33.4Dayspresent9-5 per 6months82.788.993.594.297.4100.0Dayspresent9-5 per 6months3.23.43.63.63.73.8Comparison NWD availability across different working patterns- Resident- The NWD availability on the resident rotas are fairly comparableand perhaps more favourable with a 24 hour partial shift.RotatypeNumberof juniorson rota6789101112131456 hour rota 48 hour rotaFull shift (56hrs) Full shift (48hrs) PS16 (non-res) PS24 (non-res)Dayspresent9-5 per 6months65.374.080.582.784.485.8Dayspresent9-5 per 6months2.52.83.13.23.23.3Dayspresent9-5 per 6months43.755.464.371.174.078.782.786.087.0Dayspresent9-5 per 6months1.72.12.52.72.83.03.23.33.3Dayspresent9-5 per 6months4855.464.371.176.678.782.786.087.0Dayspresent9-5 per 6months1.82.12.52.72.93.03.23.33.3Days Dayspresent present9-5 per 6 9-5 per 6months months48.0 1.859.1 2.367.5 2.671.1 2.778.8 2.981.1 3.184.8 3.388.0 3.140

Support, Evidence and GuidanceConclusionGood rota design is not easy, and can be a timeconsuming exercise when done well. Hopefully it hasbeen clearly demonstrated that time invested in rotadesign is time well spent. It’s hoped this booklet willprovide useful information to support NHS trusts in themove towards full WTD 48 hour compliance for alljunior doctors.Best of luck to you all.Yasmin and Masood41

9. AppendicesAppendix ASoftware tools available tosupport rota designDoctors Rostering Systemwww.drsusers.com‘Rotaworks’, Zircadianwww.zircadian.com42

Appendix B Example Bleep PoliciesExample bleep policy 1Title: Bleep Policy – Contacting Medical Staff and theHospital at Night Team.Authors Name: Brenda Blackett – project managerScope: trust wideClassification: policyReplaces:Contacting Medical Staff (during the Normal Working Day and Out of Hours), 2003.To be read in conjunction with the following documents:Resuscitation policy, SRFT policy.Unique Identifier: Review Date: October 2008HR11(07)Issue Status: Draft 1 Issue No: Issue Date:Authorised by:Authorisation Date:Document for Public Display: YesAfter this document is withdrawn from use it must be kept in an archive for __ years.Archive:Date added to Archive:Officer responsible for archive:Policy StatementMedical staff should be available via their bleep or pager to ensure registered professionals are able to contactthem as a matter of urgency. However as doctors working hours are being reduced in line with the WTD 2009 theinefficient use of the bleep system can disrupt their workload, and as a consequenceroutine tasks take longer to complete with the effect of those not completed being passed inappropriately to theout of hours service.There need to be guidelines for contacting medical staff during normal working hours, and in conjunction with theHospital at Night project for contacting medical staff during the out of hours service, in order to consolidateexisting good practice relating to effective communication and patient safety between the multidisciplinary teams.43

1.0 Roles and responsibilities:1.1 The executive medical director and executive nursedirector are responsible for ensuring trust widecompliance with the policy.1.2 All medical staff are responsible to the executivemedical director to ensure individual compliancewith this policy.1.3 Deputy director of nursing and governance, ADNSand matron are responsible to the executive nursedirector to ensure the policy is implemented withineach directorate across the trust.1.4 Ward/ department managers have a responsibilityto the ADNS and matron for implementing thepolicy at local level and ensuring compliance.1.5 All trust staff have a responsibility to comply withthe policy.2.0 Protocol2.1 Crash calls and life threatening emergencies.● The crash call procedure is initiated by theswitch operator on receipt of a 2222 call fromany ward or department.2.2 Contacting Medical Staff during Normal WorkingHours.During normal working hours medical staff should onlybe bleeped between their routine visit to the ward forgenuine urgencies.In order to reduce the need to use the bleep systemguidelines have been developed to enhance effectivecommunication between the medical staff and clinicalareas.• The doctor should communicate the next plannedvisit to the clinical area to the coordinator• The doctor is responsible for informing the clinicalarea coordinator of any bleep free time (for breaks,study, attendance of handover etc)• There should be a communication system in theclinical area (book, whiteboard etc) where all tasksand nonurgent work for medical staff can be loggedfor the next planned visit• Medical staff can also leave nonurgent messages orcomments using the above method.• All nonurgent routine work should be completed bythe ward based team during normal working hoursto reduce the amount of uncompleted work passedon to the out of hours’ team• The doctor must contact the coordinator of theclinical area on arrival and before departure.If there is the need to bleep the medical staff for urgentreasons the following guidelines should be used:• If possible the ward coordinator or shift leadershould be responsible for contacting andcommunicating with the doctor• The trust EWS algorithm should be followed if apatient has a score of three or above• All bleeps made to doctors should be logged withtime, bleep number and reason for the bleep in thepatient’s care record by the nurse responsible forbleeping and communicating with the doctor.2.3 Contacting medical staff out of hours.• Between the hours of 5pm and 9pm weekdays anddaytime at weekends from 7.30am until 9pm theMedical Staff must only be bleeped for urgent calls,as during normal working hours, with routine jobsbeing allocated to the on call teams planned visits• Wards must utilize staff with extended role skills tocomplete patient care where appropriate(venepuncture, cannulation, catheterization etc)calling for medical assistance only when a patients’condition determines the need for medical input• Out of hours between the hours of 9pm and 7.30am the Hospital at Night Team is responsible for thereview of patients across the trust (excludingspecialty services which will continue to use thebleep method for contacting their on call team), andall calls must be filtered through to the night sitecoordinator via the rapid response system or bleep3092, to allow the priority of patient care and theallocation of each request to the most appropriatelycompetent member of the available Hospital atNight Team.• The Hospital at Night team consists of:• Medical and surgical on call doctors from 9pmuntil 7.30am (excluding specialty services)• The night site coordinator• The bed manager• nurse clinician• clinical support.All bleeps/calls to medical staff, nurse clinician andclinical support must be directed to the night sitecoordinator between the hours of 9pm and 7.30 am(via the Rapid Response System or Bleep 3092). Anybleep directly to the above members of the hospital atnight team between these hours will be redirected bythe individual to the night site coordinator.44

Appendices• Bleep filtering is a key component of Hospital atNight as it minimizes the inappropriate bleeping ofdoctors and helps redistribute work effectively. SeeAppendix 1 for Hospital at Night bleep filteringChart.• The process of Bleep Filtering will be assisted by theTrust rapid response Bleep Filtering System inconjunction with the Hospital at Night project.3.0 Policy implementation plan3.1 This Policy will be placed on synapse forinformation.3.2 All ADNS, matrons, lead nurses and ward managerswill be responsible for the distribution andimplementation of the policy in their clinical area.3.3 The executive medical director will be responsiblefor the dissemination of the policy to all doctors/medical staff within the trust.3.4 A date for the commencement of the bleepfiltering will be set between the project manager,night site coordinator and the Hospital at Nightteam, with the ADNS, matrons, lead nurses, wardmanagers and clinical areas aware of a live dateensuring all staff comply with the policy.3.5 The ward managers need to ensure adequatenumbers of staff are trained where appropriate inenhanced roles and that these skills are thenutilized in accordance with the policy.4.0 Monitoring and review4.1 It’s the responsibility of medical and nursing staffto monitor the compliance with this policy on anongoing basis, reporting any noncompliance totheir clinical lead.4.2 The night site coordinator has a responsibility on aregular basis to evaluate the effectiveness of thebleep filtering in conjunction with the Hospital atNight Team.On implementation of the rapid response systemin the trust accurate audit data will be availablefrom the system for review.45

Bleep Filtering ChartHospital At Night bleep filtering between 21.00hrs and 07.30 hrsAll ward staff must follow this chart between these hours. Any call directly to individualmembers of the Hospital at Night Team will be redirected by the individual to theHospital at Night site coordinator.Ward patient requiresreviewNon emergencyrequiring medicalassistance, support oradvice during the shift.Crash call / lifethreatening emergencyrequiring immediatemedical assistance.Check first!Are nursing staffavailable on the ward/unit with competenciesto complete the task?Eg venepuncture,cannulation, urinarycatheterisation or ECGNo?Contact nightsite coordinator forbleep filtering toHospital at Night teamvia the rapid responsesystem or bleep 3092Follow crash callprocedure or tofast bleep doctorring 222246

AppendicesEndorsed by:Name of lead clinician/manager or Position of endorser or name of Datecommittee chairendorsing committeeBob Young medical consultant May 2007Chris Ward ADNS critical care April 2007Stephen Waldeck executive medical director April 200747

Record of Changes to Document - Issue number: 3Changes approved in this document by - Corporate Governance and Risk Management Date: 7/7/05Section Amendment Deletion Addition ReasonNumber (shown in bold italics)48

AppendicesExample bleep policy 2Hospital At Night and iBleep PolicyAll outstanding ward requests to be entered oniBleep from 20:00.General Surgery● Handover at 20:00 SHARP● An all doctor bleep will go out at 19:50● Assemble in night team office● Night coordinator will lead the handover● No one may leave until the handover is completed,this will be enforced● Night coordinator to record all sick patients and alloutstanding jobs on the night proforma● Needs full name first (SHO) will cross cover withurology● Needs full name first (SpR) is non resident from22:00● All request for SpR calls via switch after this time.UrologyStockportNHS Foundation TrustTrauma And Orthopaedics● Handover 20:00● An all doctor bleep will go out at 19:50● Assemble in night team office● Night coordinator will lead the handover● No one may leave until the handover is completed,this will be enforced● Night coordinator to record all sick patients and alloutstanding jobs on the night proforma. Note: As of5th August, there is no cross over● SpR is non resident from 22:00● All request for SpR calls via switch after this time.Remember, if you request the registrar to attend,let the night coordinator know when the registraris on site● Handover at 20:00 SHARP● An all doctor bleep will go out at 19:50● Assemble in night team office● Night coordinator will lead the handover● No one may leave until the handover is completed,this will be enforced● Night coordinator to record all sick patients and alloutstanding jobs on the night proforma● SHO will cross cover with general surgery● SpR is non resident from 22:00● All request for SpR calls via switch after this time.49

Example bleep policy 3Manchester Mental Healthand Social Care TrustJunior Doctors Bleep ProcedureIntroductionThis policy seeks to consolidate existing good practicerelating to communication between nursing andmedical staff.A bleep is a device that enables urgent contact to bemade with junior doctors (needs to be explicit). It’scounter productive if used for routine, non urgent calls.In general a bleep should not be used unless there is agood reason to call the doctor immediately.Aims• To make the most effective use of junior doctorclinical time• To enable junior doctors to take the necessary breaksto comply with the New Deal and Working TimeDirective (WTD)• To aid communication between medical and nonmedical staff• To ensure that the bleep system is used for urgentcalls only.Protected HoursParticular care should be taken when bleeping doctorsbetween the following times, to ensure that naturalbreaks and continuous rest (in order to comply with theNew Deal and WTD) are achieved:12:00 – 14:0017:00 – 19:0022:00 – 08:00Within these hours doctors should only be bleeped forurgent calls (defined below).Life Threatening EmergenciesIn this situation, the crash team should be called accordingto procedure. Where the crash call has been replaced witha 999 call the junior doctor should be bleeped.Urgent CallsUrgent calls are defined as:• Any major change in a patient’s general conditionthat will not wait until the doctor’s next routine visit• Distressing symptoms, which may cause the patientundue suffering if not dealt with before the nextroutine visit of the doctor to the ward• Relatives requiring to speak with the doctor becauseof deterioration in a patient’s condition• The arrival of an urgent admission• A & E presentations• Suicide presentation• OverdosesThis list is not exhaustive.Non Urgent CallsGood planning can reduce the need for non urgentbleeps. Junior doctors should take care to communicatewith nursing staff during the day to ensure that allroutine ward work, which cannot be delayed until theirnext planned visit, is completed.When bleeping a doctor it should be consideredwhether the issue could wait for the next planned visitof the doctor. To facilitate this:• The ward should be aware of the doctors nextplanned visit. A system should be in place so theward will have a readily available record of thedoctor’s next visit• Out of usual working hours medical staff should visitall wards at pre arranged time(s) to deal with queriesor problems. Although it’s recognised thatunforeseen events and emergencies will takeprecedent and therefore delays to visits are possible• Each ward should keep a list or book tocommunicate requirements/tasks for the juniordoctor at the next ward visit. Nursing staff should listall the routine and non urgent tasks for the doctorto carry out. The doctor should confirm with thenursing staff that an item has been completed andsign the list or book for verification.50

AppendicesJunior doctors should not be called to deal with thefollowing matters, particularly within the protectedhours defined above:• If a patient suffers a mild fall (and the nursing teamis confident there has been no injury) or is brieflymissing, where there is a member of the nursemanagement team available to deal with this• The writing/rewriting of prescription charts. It’stherefore essential that junior doctors ensure theyhave written up or rewritten any necessaryprescription charts before the end of their shift• To take routine bloods.MonitoringThe effectiveness of this policy will be monitoredthrough the six monthly Department of HealthMinisterial Returns. These returns will highlight whetherthere is an improvement in compliance with the restrequirements of the New Deal and WTD.This list is not exhaustive.Bleep Holders DutiesBleep holders have a duty to answer calls promptly. Ifthis is not possible, ask someone else to answer for you,take a message and determine if the message is urgentor not. When a patient is seen, a note should be madein the patients record of the time, date, details and anyaction taken.Using a BleepBetween 09:00 and 17:00 a designated member of thenursing team within a ward will be responsible forcoordinating the usage of the bleep system. It will bedecided locally who will take on this responsibility. Thisshould avoid unnecessary duplication of calls.Between 17:00 and 09:00 the night manager willcoordinate all calls to the bleep. The night manager willbe responsible for ensuring that the doctor is bleepedaccording to this policy (at Manchester Royal Infirmarybetween 17:00 and 09:00 the doctor will continue tobe bleeped by a designated member of the nursingteam within a ward).All managers must ensure that those responsible forbleeping doctors comply with this policy.51

Appendix CSample WTD policySouth Manchester Hospitals(NHS) TrustMonitoring Of Hours Policy –Junior Doctors3.2 The study of all rotas will be performed over a sixmonth period starting April and October each year3.3 Monitoring will be undertaken for a period of 14days to include two weekends, or for a periodagreed with the clinical director3.4 If there is disagreement about the outcome of awork study, or if the results are inconclusive, afurther exercise will be taken within the specialty.1.0 IntroductionSouth Manchester Hospitals NHS Trust is committed tosafe working practices for all junior doctors in training.The New Deal as set out in HSC 1998/240 and theWorking Time Directive (WTD) that came into effect on1st August 2004, set down standards that put limits onthe hours that junior doctors work, thus ensuring thatadequate rest is taken.It’s recognised that a continuous and robust system ofmonitoring junior doctors’ hours and work intensity isestablished that involves all junior doctors within thetrust. Monitoring of hours is a mutual obligation forboth the employer and the junior doctor.The implementation of the new pay banding system inDecember 2000 was dependent upon the capture oftimely and accurate monitoring data. The arrangementsset out in this policy will ensure that where possible paybanding will accurately reflect the intensity and hoursthat the doctors actually work.2.0 Who The Policy Applies ToThe policy applies to all junior doctors who work atSouth Manchester Hospitals NHS trust. It also includesdoctors who participate in rotas which include juniordoctors in training, so that an accurate assessment ofthe doctors’ workload can be made. This includesresearchers, and staff grades.3.0 Method Of Monitoring3.1 Paper work diaries will be issued to each doctorparticipating in the work study4.0 Analysis And Evaluation4.1 The information received from the work intensitystudies will be analysed by the medical personneldepartment and a summary report will besubmitted to each division, directorate, theimproving junior doctors working lives (IJDWL)team at the strategic health authority (SHA), theexecutive board and the trust board.5.0 Pay Banding5.1 Pay banding for additional duty hours will bedependent on the results of monitoring.5.2 Pay bands are allocated as Appendix One.5.3 Where a pay band is disputed, junior doctorsmust:• Monitor their working pattern for a period of14 days, to include two weekends• The findings will then be discussed at ahearing. The panel will include, the clinicaldirector, the directorate manager, the medicalpersonnel manager and at least one juniordoctor from the rota.5.4 If following monitoring, a decision to reduce a payband is made on the basis of change to workingpractice, the following information must be sent tothe IJDWL team:• Details of any change in working practice• The monitoring data analysis• The agreement of the post holder(s)• The agreement of the clinical tutor.52

Appendices5.4 Where a pay band is changed to a lesser amount,junior doctors will have their pay protected as perAppendix Two.6.0 Responsibility Of The Medical PersonnelDepartmentIt’s the responsibility of the medical personneldepartment:• To examine, advise and provide solutions on juniordoctor rotas• To facilitate monitoring studies for each juniordoctor rota• To summarise and analyse studies in accordancewith NHS Executive guidelines• To compare results of monitoring with New Dealand WTD criteria and highlight areas of noncompliance• To facilitate the pay banding process. Decisionsshould be made on the basis of valid and accuratemonitoring studies• To ensure that senior and junior doctors, managersand nursing staff are educated and aware of theNew Deal.8.0 Responsibility Of The Junior DoctorIt is the responsibility of the junior doctor to:• Record data on hours worked when asked to doso by the trust as set out in the terms andconditions of service• Forward recorded data to the medical personneldepartment promptly for analysis and evaluation• Work with the trust to identify appropriateworking arrangements or other organisationalchanges in working practice, when changes to arota are deemed to be necessary• Comply with changes to working practice whenimplemented• Be proactive about taking rest and natural breaksas set out in the New Deal and WTD• Make the trust aware if they work hours that aredifferent than those set out in the rota.9.0 WTD And Compensatory Rest7.0 Responsibility Of The Division7.1 It’s the responsibility the division to ensure thatevery junior doctor participates in the workintensity studies as set out in terms and conditionsof service. Sanctions in the event of failure tomonitor are set out at Appendix Three.9.1 The WTD stipulates that 11 hours continuous restshould be achieved as a minimum period off dutybetween duty periods. Where 11 hours continuousrest is not achieved, junior doctors will beexpected to take compensatory rest in unpaid timeas soon as their duty is complete.7.2 Clinical Directors and Directorate Managers willwork with the doctors participating on the juniordoctor rota to address any difficulties, exploringalternative arrangements and working patternswith the aim of finding solutions in order to ensurethat rotas comply with the New Deal and WTD.7.2 The Medical Personnel Manager will provideassistance where needed, offering support andadvice to divisions.53

Pay Banding SupplementsBand: average hours From 1/12/00 From 1/12/01 From 1/12/023 non compliant with 62% (1.62) 70% (1.72) 100% (2)New Deal2A 48-56 hours 50 (1.5) 60% (1.6) 80% (1.8)most intense2B 48-56 hours 42% (1.42) 42% (1.42) 50% (1.5)least intense1A 40-48 hours 42% (1.42) 42% (1.42) 50% (1.5)most intense1B 40-48 hours 30% (1.3) 30% (1.3) 40% (1.4)middle intensity1C 40-48 hours least intense 20% (1.2) 20% (1.2) 20% (1.2)The total salary of junior doctors will comprise of a base salary to which a non pensionable supplement calculated.The figure in brackets shows the total salary expressed as a multiple of the base salary.54

AppendicesAppendix DExample natural break policyTitle: Junior Doctor Hours andBreaks Breach PolicyPurpose:To ensure junior doctors hours of work comply with therequirements and limits of working as set out underNew Deal and European Working Time Directive.Documentation Application:This policy relates to all junior doctors.Responsibilities For Implementation:Trustwide responsibility is required for the success in theimplementation of this policy. Directorate managers arerequired to investigate a breach of shift or naturalbreak.Date Issued:August 2007Date Revised:n/aReview Date:August 2008Author:Noreen Akram, human resourcesReferences (If Applicable):Intranet Category For Location:Human resourcesBackground1.1 Under terms and conditions of service, all juniordoctors in training (includes junior doctors in nontraining posts participating on the rota andreferred to as junior doctors hereafter) are requiredto comply with the requirements and limits onhours of working as set out in HSC 1998/240 andHSC 2003/001. The trust and junior doctors have aduty to ensure that junior doctors work within theapproved working pattern for their grade andspecialty.1.2 Junior doctors and the trust have a jointresponsibility to ensure that they do notcommence or finish work later than the agreedstart and end times. In addition, it sets out theresponsibilities of the junior doctor to takewhatever action is necessary to ensure a naturalbreak is taken and the process to follow in thesituation where a natural break cannot be takenwithin the timeframe outlined in section 3 below.1.3 It’s imperative that the each division introducessuch mechanisms to safeguard not only the healthand safety of its junior doctors but also to ensurethat they are well rested to provide the highestquality of care to our patients. Failure toimplement this policy effectively also puts juniordoctor posts at risk of becoming non compliantand attracting pay band 3.Shift lengths2.1 It’s not uncommon for junior doctors to arrive attheir workplace earlier than the start time of theirshift, often to avoid traffic or to attend consultantsmeetings. Unless instructed to do so by anauthorised and senior member of the trust, theyshould not declare this as time in work as this istheir own free time.55

2.2 Similarly to 2.1 above, where a junior doctor doesnot leave their workplace at the end of their shifttime, it should not be declared as time in workunless instructed to do so by an authorised andsenior member of the trust.2.3 Doctors working on an on call rota providing oncall duties Monday to Thursday nights are requiredto be on duty no more than 32 hours at a stretch.For this to be possible, finishing times on the dayfollowing on call must adhere to the followingprinciples:2.3.1 Any doctors presenting themselves earlierthan 9.00am at the commencement of theiron-call day, do so at their own volition andmust notify the Directorate Manager of theirreasons for doing so.2.3.2 Doctors providing on-call that day, who havecommenced duty at 9.00am, must completetheir duties at 3.00pm the following day.They are not required to be present afterthat time.2.3.3 If due to clinical commitments, it appearslikely that the shift will extend beyond therequired finishing time, the junior doctormust notify their consultant for advice nolater than an hour before the scheduledfinish time. The directorate manager shouldalso be notified who will record this fact (seeAppendix A – Hours Breach Report) and anyagreement made with the consultant onbehalf of the trust to extend the finish time.Any extension to the finishing time must besolely for emergency clinical work.2.4 Wherever possible, junior doctors shall not berostered for commitments such as clinics, post oncall.If they are, the trust must ensure that theycan leave that clinic early. For example if the endof shift time is 3pm, post on call, and the juniordoctor is required to attend clinic in the afternoon,they must leave clinic at 3pm. Failure to do so willresult in the post becoming non compliant andBand 3.2.5 In most circumstances, the junior doctor will berequired to finish at their designated time. Only inexceptional circumstances will they be required tocontinue working after this time.Natural Breaks3.1 Junior doctors must ensure that they take therequired half hour break for their working pattern.For example, for a standard working day of 9am –5pm, a natural break should be taken betweenmidday and 2.00pm Monday to Friday.3.2 It will be the junior doctors’ responsibility to take acontinuous suitable break of 30 minutes, notifyingtheir immediate clinical team that they are taking abreak and that they are not to be contactedexcept in an emergency.3.3 Junior doctors should notify the directoratemanager when it has not been possible to take asuitable break, citing the reasons for this. Thedirectorate manager will record each breach (seeAppendix B – Natural Break Breach Report). Theseincidents will then be taken up with the relevantconsultant team by the directorate manager toensure full compliance with this aspect of thejunior doctors’ hours regulations.3.4 Theatre and clinic overruns will become theresponsibility of the consultant where they arerequired to relieve junior doctors of their duties sothat they can take a natural break. The consultantmust make it explicit to the junior doctor that theyare required to take a break.3.5 If the junior doctor wishes to forfeit their naturalbreak for their own reasons, they may do so butthis will not be at the behest of the trust, andcannot form the basis of a failure by the trust tocomply with Working Time Directive (WTD) or NewDeal, nor can it result in posts being allocated payband 3. If a junior doctor forfeits their naturalbreak of their own volition, they must also reportthis on every occasion to the directorate managerwhere it will be recorded accordingly.Responsibilities4.1 All directorate managers in conjunction with theirconsultant team should ensure mechanisms are inplace to support the taking of natural breaks. Aspart of this process, notices on wards and wardphones should inform other ward staff of therequirement for junior doctors to take natural56

Appendicesbreaks and set out ‘bleep free’ periods when wardstaff should refrain from contacting junior medicalstaff (except in an emergency).4.2 It will be the junior doctors’ responsibility to take asuitable break, notifying their immediate clinicalteam that they are taking a break and that theyare not to be contacted for a period of 30minutes, except in an emergency.Communication5.1 The above requirements will be communicatedwidely to all consultant teams, nursing staff,directorate managers, divisional general managersand the wards. Explicit reference to thesearrangements will be made at junior doctorinduction with a hard copy handed out to all newappointments.5.2 Each directorate will feedback to junior doctorsregularly regarding overruns and incidents whichprecluded junior doctors from taking a naturalbreaks and complying with the working pattern.Agreement and Review Date6.1 This agreement has been reached with thedivisions and representatives of the (needs fullunabbreviated names first) SHO and SpR grade.6.2 This policy will be reviewed annually followingeach period of monitoring or earlier if the needarises.6.3 This policy has been approved by the capital andworkforce planning meeting held on 6th July2007.Implementation date: 1st August 2007Review Date: Following annual monitoring of juniordoctor hours or earlier if required57

Hours Breach ReportNameGradeDepartmentBleep numberE mailConsultantDayDateWorking patternFull shiftOn call rotaNo on callOther (specify)Shift typeNormal working dayLong dayNight shiftOther (specify)Type of breach(tick as many as applicable)Early start (than agreed start time)Late finish (than agreed finish time)Was the breach voluntary? Yes NoWho did you notify?NameWard sisterDirectorate managerConsultantSpRSHOWhy did you start earlier/finish laterthan your agreed start/finish time?(this section must be completed in detail)What action was taken by the person you notified?Please forward this form to your medical staffing department within 24 hours of your failureto take a natural break.For office use Referred to DGM DD DM CD Other(specify below)Other action taken58

Hours Breach ReportNameGradeDepartmentBleep numberE mailConsultantDay and dateShift timesShift typeNormal working dayLong dayNight shiftOther (specify)Type of breach(tick as many as applicable)Lunch breakEarly evening break (for doctors on long days)Night shift break (early 20:00 to 02:00)Night shift break (late 02:00 to 08:00)Was the failure to take a natural break voluntary? Yes NoWho did you notify?NameWard sisterDirectorate managerConsultantSpRSHOWhy was it not possible to take a break?(this section must be completed in detail)What action was taken by the person you notified?Please forward this form to your medical staffing department within 24 hours of your failureto take a natural break.For office use Referred to DGM DD DM CD Other(specify below)Other action taken59

Example natural break policy 2Guidance on DirectorateProtocols For Natural BreaksDo You Give Your JuniorDoctors A Break?●●Have other colleagues been briefed whereappropriate ie senior colleagues and nursing staff, toexpect and respect that junior doctors will be takingthese breaks?Since education is counted as work under the NewDeal, if lunches are provided in connection withteaching sessions, are these lunches at least a halfhour duration, and before the commencement ofthe formal teaching?Under the New Deal Regulations for house officers,senior house officers and specialist registrars, thefollowing applies to the provision of ‘natural breaks’.“Within full shifts natural breaks will be needed awayfrom clinical duty. It is reasonable to provide at least a30 minutes break after approximately four hours’continuous duty. Trusts should devise working practiceswhich allow proper cover for these absences (thesenatural breaks must also, of course, be provided duringthe normal working day, for doctors on on call rotas orpartial shifts and should not be considered part of theirrest periods).” – Quote must be citedThis is a new requirement, and a change of culture, andneeds the trust to manage not just the work but thebreaks of the doctors. For normal working days, itmeans getting a lunch break of at least 30uninterrupted minutes at some time ideally between12pm and 2pm. Also for those doctors working alonger duty say 9am to 11pm, it means both a lunchand ‘teatime’ break. Uninterrupted means bleep free(except for emergencies / crash bleeps).Directorate Checklist●●●●Do junior doctors in your directorate have writtenprotocols in place for these breaks?Are these protocols robust and working in practice?For instance, what is done to ensure that the on calldoctor receives their breaks?Is the trust bleep policy adhered to, so that lunchtime break is protected apart from emergencybleeps?Are new doctors in February and August briefed andaware of the requirements and encouraged toobserve their breaks as part of the process of havingtheir duty patterns fully explained?●●●Travelling between sites is counted as work and notas a break. Is traveling time allowed for in additionto time for natural breaks when considering whenmorning duties end and afternoon fixedcommitments begin?Have the directorate’s written protocols on naturalbreaks been copied to the New Deal project officerfor reference when carrying out New Dealmonitoring of the junior doctors?Is there a mechanism for reporting any problems thejuniors may have in taking these breaks? Whoshould they report to? Is this included in the writtenprotocol?Why Treat This As Important?As the overall hours targets are met for junior doctors,the focus shifts to the rest targets under New Deal, andto the requirement to be able to take breaks. Breaksmust be taken to meet New Deal.From August 2003 they are a contractual requirementfor all junior doctors. The trust monitors junior doctors’hours at least once every six months and this includesthe taking of natural breaks. They must be taken on atleast 75% of occasions, during every type of duty thatthe doctor works.If natural breaks are not taken as required, the trustcould face a claim for Band 3 pay banding for all juniordoctors on that duty pattern. This is a significantfinancial penalty. Also continual non compliance ofposts and/or no action to resolve could lead to thepostgraduate dean removing training recognitiontemporarily and ultimately taking this away forever. Thiswould lead to the loss of 100% basic salary fundingand difficult to recruit to trust grade posts.The trust directorate management needs to firmlyimplement these breaks, and work with the doctors toimprove the protocols where they do not prove60

Appendicespractical, asking the doctors to flag up any problems, inwriting to the directorate, as soon as possible.JUNIOR DOCTOR – TAKE YOUR BREAKSRole of Medical HRAt the juniors trust induction day, natural breaks arediscussed in the context of New Deal regulations andmonitoring. We will point the doctors in the direction ofbeing aware of and adhering to their directoratesprotocols and policies in this regard.Any problems revealed through the regular monitoringcarried out by medical HR will be reported to thedirectorate.Please find enclosed a poster which may be used as partof the directorates induction process, or within thedirectorates written protocols, including for doctorsjoining at times other than the August/Februarychangeover dates ie specialist registrars etc.Roland TurnerNew Deal project officer - medical HRIt’s A Natural Break!IT’S A NATURAL BREAK !AT LEAST 30mins EVERY 4 HOURSDO YOU KNOW AND ADHERE TO THE BREAKPROTOCOLS WITHIN YOUR DIRECTORATE? IT ISREQUIRED IN YOUR CONTRACT, UNDER THE NEWDEAL RULES, TO TAKE THEM (EXCEPT INEMERGENCY OR EXCEPTIONAL CIRCUMSTANCES).NOT TEN MINUTES SNACKING A QUICK SANDWICHWHILST FILLING IN THE PAPERWORK AND GULPINGDOWN A QUICK DRINK ON THE WARD, BUT APROPER BREAK !For all Junior doctors, the following applies, to theprovision of “natural breaks”.“Within full shifts natural breaks will be needed awayfrom clinical duty. It is reasonable to provide at leasta 30 minutes break after approximately fourhours’ continuous duty. Trusts should devise workingpractices which allow proper cover for these absences.(These natural breaks must also, of course, beprovided during the normal working day, fordoctors on on-call rotas or partial shifts and should notbe considered part of their rest periods.)”SO FOLLOW THE PROTOCOL AND TAKE A BREAK.IF THE PROTOCOL ISN’T WORKING – LET THEDIRECTORATE KNOW IN WRITING AS SOON ASPOSSIBLE, SO ACTION CAN BE TAKEN.61

Appendix EBanding Appeal GuidanceProtocol for the rebranding ofTraining grade postsIssue1. There has been some confusion and variablequality of process during the exercise to bringPRHO posts into compliance for the 1st August2001. As a result, the national issue of furtherjoint guidance and documentation is felt necessary.Action2. Regional Action Teams must:Ensure that in all instances where rebanding ofposts is carried out, the process as laid out in theattached proforma document is followed in allcases, and recorded using the proforma a copy ofwhich will be retained by the Regional ActionTeam together with supporting documentation.Background3. The procedure for re-banding existing posts is laidout in Advance Letter AL(MD)2001/01, in Termsand Conditions of Service, and added to by SteveBarnett’s letter to the service of 12 March 2001.The department and the BMA agree that amechanism which rebands posts using in-postmonitoring, rather than assessment of complianceon paper or using other theoretical means, is theproper way of proceeding in the vast majority ofcases. Such rebanding is most effectively carriedout midpost in, for example, May or November, toallow rotas to bed in and to allow ‘fine tuning’after monitoring. Both sides accept, however, thatthere will be a few occasions, where significantchanges to rotas or staffing levels make itimpractical to fully implement changes to workingpractices before new staff come into post, where itwill be necessary to assess the likely banding of arota in advance of its implementation, to allow anemployer to offer posts to new employees on arealistic basis.4. Such occasions will be rare. It cannot be taken forgranted, for example, that full shifts will always becompliant as natural breaks may not be achievedor shifts may overrun. Similarly, the restrequirements of other types of rota pattern cannotbe assumed and it will therefore not beappropriate to assume that particular workingpatterns can be offered at a predicted band.However where for example servicereconfiguration or merger means that it is notpossible to implement and monitor a full rotabefore it’s proposed date of introduction, thefacility is needed to allow an employer to offer apost at an expected band. This must be dependantupon the employer demonstrating to thesatisfaction of the Action Team that it was notpossible to implement a full rota in advance,although the employer should where possiblemake arrangements to test in advance those partsof the new arrangements most likely to be noncompliant. It also places a responsibility on theemployer to monitor and confirm the bandingwithin a fixed timescale following the introductionof the new working arrangements.5. The proforma attached covers the normalrebanding process, with the facility to allow for theprovisional rebanding of a post in advance ofpractical monitoring.6. As with all instances of backdating pay under thebanding system, repayment where a lower bandthat has been paid is subsequently found to beinappropriate must be paid from when salaries atthe provisional lower band were first paid62

AppendicesNotes1. The proforma should be used both as a checklistto ensure that all the necessary stages of therebanding process have been adhered to, and as arecord of the process for payroll purposes.2. Column headings are to be interpreted as:- Stage: a step in the process which must becompleted- Evidence required: documentation/data/inputthat must be available in order to facilitate adecision at the relevant stage- Documentation: the formal confirmation thatthe stage has been followed through tosuccessful completion.3. In the proforma, references to the action teamshould be taken to refer to the Regional Improvingjunior doctors working lives action team or anysuccessor body.4. Where a decision from the Action Team isindicated, such a decision must be agreed by at aminimum, both a junior doctor employee and aBMA junior doctor representative, and will becoordinated by an officer acting with the fullauthority of, and nominated by the Action TeamChair.6. In recognition of the range of different monitoringprocesses used in the regions and not wishingeither to duplicate current practices or to create anunnecessary burden on trusts we do not proposeto be prescriptive in the way supportingmonitoring data is to be presented. However:- evidence of monitoring must conform to therequirements of the documentation issued asguidance accompanying HSC 2000/031- monitoring and/or analysis data produced bysome software packages such as ND2000 willbe acceptable for the purpose of this exercise –further guidance will be issued in due course.7. Where provisional banding is authorisedmonitoring should take place within six weeks ofthe implementation of new workingarrangements, and all necessary actions taken toensure that the results of the monitoring arereflected in banding and salary.5. The order of the stages in the Proforma does notfollow the order stated in AL(MD)1/01; this is tofollow a logical process. It would for example beappropriate in most cases for the Action Team todiscuss and agree revised arrangements withjuniors and their employers in advance of seekingeducational approval.63

Approval To Change BandTrust:Hospital:Specialty(ies):Numbers of doctors in working arrangement by gradePRHO: SHO: SpR: OtherWorking pattern:Current banding: Proposed banding: Effective date:Stage Evidence required Documentation Confirmed Y/N1a.Consult post holders onproposed changes andobtain agreement of themajority participating inthe working arrangements.Approval of majority ofcurrent/incoming postholdersTemplate signed by trustjunior doctor representativeconfirming agreement ofmajority of current/incomingpost holders1b.Submit details of the newworking arrangements tothe action team forinformation and invitedcomment.1c. Obtain agreement fromClinical Tutor for educationpurposes.Full details of proposedworking arrangements and/orrota summary (eg fromND2000 software)Full details of proposedworking arrangementsComments of Action TeamLetter signed by action teamchair or delegated authorityconfirming theoreticalcompliance of workingarrangementsLetter signed by dean ordelegated authority confirmingeducational acceptability ofworking arrangementsIf exceptionally and because of the impracticality of full implementation of new working arrangements a trust wishes to offerfuture posts at an expected banding in advance of actual monitoring, approval must be sought from the regional action team(or its equivalent) in advance of making any such offer. Any offer made in these circumstances will be strictly provisional, andmust be confirmed by monitoring following the implementation of new working arrangements.Stage Evidence required Verification Confirmed Y/N2. Submit request forprovisional approval ofworking arrangements toAction TeamSigned letter from trust givingreasons for inability to fullymonitor before rebanding.Evidence of full or partialtesting/monitoring of proposedarrangementsLetter signed by ActionTeam Chair or delegatedauthority authorising anoffer of provisional banding.Current Banding: Provisional New Banding: Implementation Date:Action Team SignatoryDate:Stage Evidence required Verification Confirmed Y/N3. Monitoring of workingpattern and confirmationof bandingCompleted monitoring returnsfrom 75% of doctors on rotaover full 2 week periodSummary of monitoring resultsThis signed templatePrevious banding: Verified New Banding: Effective Date:Trust signatory(Designation)Rota signatory(Designation)Action team signatory(Designation)Date:Date:Date:64

AppendicesAppendix FFurther informationNew Deal Informationhttp://www.dh.gov.uk/PolicyAndGuidance/HumanResourcesAndTraining/ModernisingPay/JuniorDoctorContracts/JuniorDoctorContractsArticle/fs/en?CONTENT_ID=4053873&chk=77RU2UWTD Informationhttp://www.healthcareworkforce.nhs.uk/workingtimedirective.htmlhttp://www.berr.gov.uk/employment/employmentlegislation/working-time-regs/index.htmlHospital at Nighthttp://www.healthcareworkforce.nhs.uk/hospitalatnightHandoverhttp://www.bma.org.uk/ap.nsf/AttachmentsByTitle/PDFsafehandover/$FILE/safehandover.pdfNWP Rota databasehttp://www.healthcareworkforce.nhs.uk/working_time_directive/rotas%2c_handover_and_escalation_tools/wtd_compliant_rotas.htmlRota Designhttp://www.bma.org.uk/ap.nsf/AttachmentsByTitle/PDFrotadesign/$FILE/rotadesign.pdfRota Monitoringhttp://www.bma.org.uk/ap.nsf/AttachmentsByTitle/PDFrotamonitoring/$FILE/rotamonitoring.pdf65

10. References1HSC 1998/204. Working time regulations:Implementation in the NHS. Department of Health.2European Court of Justice, Case C-303/98, Sindicatode Médicos de Asistencia Pública (Simap) andConselleria de Sanidad y Consumo de la GeneralidadValenciana3European Court of Justice, Case C-151/02,Landeshauptstadt Kiel and Norbert Jaeger4Department of Health (1991) Junior doctors’ hours:the new deal. London: Department of Health.5HSC 2000/031 & appendices. Modernising pay andcontracts for hospital doctors and dentists in training.Department of Health.6Horrocks, N, Pounder, R (2006) Designing safer rotasfor junior doctors in the 48-hour week. Royal College ofPhysicians.www.rcplondon.ac.uk/pubs/contents/09446ffc-7f46-4f18-a1d0-fb5b8607b0c4.pdf.7Royal College of Anaesthetists (2007) Working TimeDirective 2009 and shift working: ways forward foranaesthetic services, training, doctor and patient safety.10Junior Doctors Committee (2004) Rota monitoring –the essentials. A doctor’s guide to rota monitoring.British Medical Association11Junior Doctors Committee (2004) Safe handover: safepatients. Guidance on clinical handover for cliniciansand managers. British Medical Association.12Modernisation Agency (2004) Rota design with theEuropean Working Time Directive.Some questions and illustrations to aid local thinking.Department of Health.13Ahmed-Little, Y, Bluck, M. The European WorkingTime Directive 2009. British Journal of HealthcareManagement 2006; 12(12): 373-376.14Horrocks N, Pounder R. Working the night shift:preparation, survival and recovery. London: RoyalCollege of Physicians, 2006.www.rcplondon.ac.uk/pubs/books/nightshift/nightshiftbooklet.pdf15Ahmed-Little, Y. Impact of shift work for juniordoctors. British Medical Journal 2007;334:777-778.8Horrocks, M, Cripps, J, Ahmed-Little, Y, Johnston, M(2008) Working Time Directive 2009: Meeting thechallenge in surgery. Royal College of Surgeons ofEngland and NHS North West.9Junior Doctors Committee (2004) Rota design madeeasy. British Medical Association66

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