Exception reporting reform FAQs

New FAQS added April 2026 - FAQ 17 onwards

FAQ 01: Who is eligible to exception report?

Exception reporting is a contractual right for those doctors and dentists who are employed on the 2016 TCS in England. Where these TCS have been mirrored in other employment contracts e.g. academic, public health and armed forces trainees we encourage employers in England to make every effort to extend the reforms set out in the framework agreement to these doctors. The ESR system can generate reports to identify eligible doctors based on pay codes.

However, a manual review of individual contracts is required for those whose contracts do not substantively mirror the 2016 TCS.  Additional details are contained within the Framework Agreement (detailed in the Scope section).

FAQ 02: At our trust, we do not extend exception reporting provisions to our locally employed doctors, what are the expectations for this group of staff?

Employers should review their locally employed doctor workforce to identify eligible residents as determined by the framework agreement and in FAQ 6. As noted above, employers are encouraged to make every effort to extend the exception reporting provisions locally to those on mirrored 2016 TCS V13 (England) terms and are encouraged to do so. 

FAQ 03: Is there any additional funding to support implementation and maintenance of the new exception reporting requirements?

There is no additional funding associated with the exception reporting reforms. There are additional administrative requirements associated with this process which will need to be taken into consideration when preparing for implementation of the reforms. We also expect there to be an increase in the amount of exception reporting following the implementation date, until such a time as any issues are resolved via work schedule reviews. Employers should take action to ensure safe working hours are maintained. 

FAQ 04: We don’t have a software system for exception reporting, how do we ensure we can implement all parts of the agreement?

If you have a local provision for exception reporting, review the 2016 TCS V13 (England) and further resources when they are available, and consider required updates. Alternatively, you may choose to undertake a tender to use an external software provider moving forward.

FAQ 05: Will doctors and dentists in training be able to submit an exception report towards the end or after they have finished their placement?

Doctors are encouraged to exception report as soon as possible, but no later than 28 days after the date of the occurance. For the end of a placement, the process is outlined in Annex D paragraph 23 of the 2016 TCS V13. If the doctor has already changed placements, any compensation will be paid and not be given as TOIL as outlined in Annex D paragraph 24. If employers experience a pattern of late submissions at the end of a rotation, they may choose to explore why this is happening. 

FAQ 06: Will an employer be fined if they have provided access information to the doctor, but it goes to their junk email folder, or they have not completed a report yet?

Access and completion fines occur only when:

• a doctor informs their employer that they are not able to access or submit an exception report and,
• Their employer fails to provide access within 7 calendar days.

A fine is not applied if the access details are created and inadvertently ends up in a junk folder, or if the doctor does not raise that they don’t have access. If access cannot be provided due to a reason outside the control of the employer, the employer can follow the process outlined in the 2016 TCS V13 (England) Schedule 05, paragraph 21.

FAQ 07: Does this reform cover SAS and speciality doctors?

No, the changes will apply to all doctors and dentists in training who are substantively employed under the 2016 TCS V13 (England). Employers can choose to extend the provisions locally to other doctors and dentists as detailed in FAQ 6.

FAQ 08: Will an employer incur an information breach fine if the doctor themselves shares the information?

No, fines for information breach will only occur when a doctor reports a suspected unauthorised breach of exception reporting information by the employer, and that breach is proven as determined by the GOSWH as per 2016 TCS V13 (England) Annex D paragraphs 33 and 34. Scenarios such as a doctor submitting their TOIL entitlement would not result in an information breach fine.

FAQ 09: What if a doctor or dentist in training chooses to work additional hours rather than is required to?  

Exception reporting does not apply to occasions where an individual may choose to undertake educational activities for personal development or career enhancing purposes, which are outside of contractual requirements, the agreed personalised work schedule or are not an essential activity to pass ARCP. 

This is set out in Schedule 05, paragraph 2 of the 2016 TCS V13 (England). 

If trainees wish to stay and do additional activities for their portfolio/personal education outside of their usual rota, an employer may consider encouraging the trainee to discuss this with their educational supervisor to incorporate all educational requirements into their personalised work schedule and gain prior approval to attend. 

FAQ 10:  What does ‘co-located in a clinical workforce’ mean?

This refers to the provision set out in Annex D, paragraph 5 and is intended to reduce the likelihood of an information breach occurring. The review of exception reports ideally should be done with privacy in mind, to avoid any unintended breach of information. Employers may also wish to consider utilising , privacy screens and confidentiality reminders to support this process. How this issue will be addressed can be discussed with your Resident Doctor's Forum (RDF) or Local Negotiating Committee (LNC) if required; particularly if there are any barriers to delivering this provision.

FAQ 11: Is the fines process optional?

No, the fines process is detailed in the 2016 TCS V13 (England) and is therefore contractual for all doctors and dentists in training on the 2016 TCS V13 (England) contract.

FAQ 12: How does the new 28-day reporting window affect exception reporting practice?

For instances of immediate safety concerns, doctors will raise this orally and follow up immediately using local processes, for example the DATIX reporting system. While it is important that doctors submit exception reports as soon as possible, the extended window to submit is now up to 28 calendar days following the date of the occurance. The reform strikes a balance between flexibility and responsiveness. This change offers doctors more flexibility to reflect and report concerns, especially during a busy rotation. A prompt submission will support a timely resolution. If a doctor submits a report after 28 days, the GOSWH can make the decision to accept the submission locally. 

FAQ 13: How will the exception reports for over two additional hours worked be managed?

Exception reports for more than two additional worked hours should be subject to a locally determined process as per 2016 TCS V13 (England) Schedule 05, paragraph 13. This process should be in addition to the process set out in the TCS for under 2 additional hours. This process will not incur an information breach fine.

FAQ 14: Do you know when exception reporting software will be ready?

NHS Employers has engaged with a group of software providers and developed a software specification. We encourage employers to engage with your providers and sign up to any updates on the delivery of updated solutions they can provide directly to you. 

FAQ 15: Does any money from the new fines introduced in 2026 go to the doctors?

No, unlike the previous fines. Fines for access and completion, or information breach fines will not be paid directly to doctors, as per 2016 TCS V13 (England) Schedule 05, paragraph 28.

FAQ 16: What measures are in place to ensure doctors submit truthful exception reports?

A: For each exception report the doctor will confirm via a self-declaration as outlined in the 2016 TCS V13 (England) Schedule 05, paragraph 9, alongside their report and evidence. Local policies also apply, such as fraud and grievance processes, which doctors should be made aware of at induction.

FAQ 17: On the 4 February 2026 implementation date, what should be done to the Guardian of Safe Working Hours (GoSWH) pot of funds from existing fines under the 2016 TCS? 

Any remaining accumulated fines under the 2016 Terms and Conditions of Service (TCS) up until 4 February 2026 will carry over to the new GOSWH central fund on 4 February 2026. 

FAQ 18: Are hourly penalty rates affected by the updated Version 13 of the 2016 TCS? 

No, they are not affected by this. Existing hourly penalty rates paid to doctors under Schedule 2, paragraph 77 and Annex A of the 2016 TCS remain unchanged. Only the GoSWH fines management and disbursement processes are adjusted.  

FAQ 19: What happens if the GoSWH is also an educational or clinical supervisor? 

This would be considered a conflict of interest if they continue to hold both roles. The guardian is likely the most appropriate person to manage that conflict. They would need to be transparent locally so the board and LNC are fully informed and have an opportunity to raise any concerns, object or accept the position and keep under review. Several actions could be taken to mitigate such conflict, including but not limited to: 

The GoSWH could relinquish the educational supervisor role, using the allocated time to perform the GoSWH duties; or 

A reciprocal arrangement between GoSWH of neighbouring trusts could be developed to manage any issues relating to trainees for which the GoSWH is an educational supervisor.

FAQ 20: Can the HR/medical staffing exception reporting responsibilities be carried out by alternative departments/staff (eg GoSWH assistants, medical education)? 

Yes, changes in Version 13 of the 2016 TCS are not intended to constrain working local process. Such processes may be validated by the RDF, LNC or equivalent. Where a Trust has no dedicated HR/medical staffing function, or where a GoSWH administrative assistant exists, alternative departments may carry out these responsibilities.  

FAQ 21: Can a medical HR colleague act as deputy to the GoSWH? 

Yes. Many organisations already follow this model. The reform does not intend to constrain existing medical HR support, which may include preparing board reports or acting as a deputy to meet the timeframes set out for the GoSWH in the TCS. The intention of Medical HR approving reports was not to restrict or remove the support to the GoSWH. 

FAQ 22: Is the DME allowed to deputise for the guardian of safe working hours? 

Yes. If the DME has capacity and agrees to be the GoSWH deputy, then this would be acceptable.

FAQ 23: Can the DME and the guardian of safe working hours have the same deputy?  

Yes. If the deputy has capacity and agrees to deputise for both, this would be acceptable.

FAQ 24: Is there a limit to how many deputies the guardian of safe working or the DME can have? 

No. This will depend on capacity and the size of the organisation, so it will not be restricted.

FAQ 25: When in the process does the evidence need to be captured? 

Evidence as per Annex D, paragraph 8ii in the 2016 TCS, refers to electronic evidence of time, date and location of the occurrence (e.g., a timestamped location), which should be captured at the start or end of the shift depending on the category of the exception report.  

Geo-location and timestamp may be substituted with written electronic corroboration of exception report details, by another regulated clinical professional, but this corroboration cannot be made a default requirement. 

FAQ 26: What should we do if a doctor often fails to provide evidence for the exception report? 

A doctor who fails to provide any evidence will not be able to claim payment for additional hours worked through an exception report. If the cause of the doctor being unable to provide either form of evidence is systemic, rather than a singular occurrence, then action should be taken to address this if possible. If a pattern emerges of reports being submitted without either form of evidence provided, and there is no underlying systemic cause for this inability to provide either form of evidence, then the GoSWH will investigate these reports in accordance with the process and procedures set out in Schedule 6, paragraph 13 of the 2016 TCS.   

Evidence submitted should be assessed to check for accuracy of location, time and date. Any suspected alterations or duplication of the same evidence should be reported to the GoSWH and investigated. 

FAQ 27: Does the evidence have to be a geo-location? 

The TCS requires electronic evidence of time, date and location. Local agreement may determine the type of evidence required, guided strictly by SFIs and finance minimum standards. The process will need sign-off at LNC and will require local finance approval.

FAQ 28: Do the evidencing requirements need to remain the same, or can they vary from department to department? 

HR/medical staffing will be processing exception reports centrally, and the presumption is that they will not know the doctors or their work schedules closely. Therefore, all exception reports will meet the same evidencing requirements. If a trust chooses to have differing requirements locally, they may do so if their financial SFI’s are met. 

FAQ 29: What checks are undertaken for fraud? 

The doctor must sign a mandatory declaration upon submission of each exception report to confirm the accuracy of the information provided. This, alongside the mandatory evidencing requirements set out in the TCS, should support the local employer SFIs for fraud control. Metadata checks on evidence submitted will be carried out, an example of this can be found in the evidencing guidance. The process does not constrict normal fraud policies or processes for escalation. NHS England shared a letter to trusts. For reports of over two additional hours, the trust will have in place a full investigation process without the risk of information breach fines. The guardian of safe working hours retains overall oversight of all reports to help with trend spotting and has the ability to raise any concerns.

FAQ 30: Can locums provide corroboration as evidence for exception reporting? 

Ideally, corroboration should come from a substantively employed colleague by the organisation, where possible, but acceptance of corroboration from locums could be acceptable, subject to local determination. For example, a regular locum taking up a full-time position on the same rota could be acceptable, subject to local agreement.

FAQ 31: Does exception reporting apply to locum or bank shifts? 

No. This process does not apply to locum (bank/agency/waiting list initiative shifts). Exception reporting applies only to doctors and dentists in training on the 2016 terms and conditions of service in England. The provision may be extended locally to those doctors and dentists who are on mirrored local contracts, but not for bank, locum or agency work as these are arranged separately to a work schedule. 

Note that pre-arranged overtime for service needs should be approved through locum processes and not via exception reporting. 

FAQ 32: Is there a minimum time that can be exception reported (for example 15 minutes)? 

The 2016 TCS V13 (England) is silent on this. However, as 15-minute blocks are referenced in work scheduling, trusts may develop local policies aligned to this.

FAQ 33: When is TOIL mandated for safety reasons? 

Where TOIL is mandated for safety reasons, it should be taken within 24 hours. Trusts should follow local leave policies to inform the appropriate scheduling of TOIL in this regard.

FAQ 34: Can consent from the doctor for information to be shared be pre-granted during the submission of the exception report to save time? 

Yes, pre-granted consent could be given during the exception report submission. This could also be discussed with the LNC level for specific processes, such as allowing for PGME to have a conversation with the DME at any point to reinstate educational opportunities.

FAQ 35: The doctor's work schedule lacks detail. What can we do? 

A personalised work schedule should be agreed between the educational supervisor and the doctor. The personalised work schedule must be agreed before or within four weeks after the commencement of the placement. Information not on the work schedule would not be evidenced for exception reports and would fail to apply. 

FAQ 36: Will a detriment survey template be available, so all trusts are asking the same questions to ensure data or approach is consistent? 

The questions required as part of NHS England's monitoring are included in the board report. 

FAQ 37: Will a detriment survey template be available, so all trusts are asking the same questions to ensure data or approach is consistent? 

The questions required as part of NHS England's monitoring are included in the board report. 

Updated guardian of safe working hours FAQs

FAQ 38: What safeguards does the contract provide to ensure that doctors work in line with their work schedule? 

The system of exception reporting outlined in the 2016 TCS ensures that departures from planned working hours, working pattern or access to planned training opportunities are recorded. Work schedule reviews should take place where this happens consistently and can be requested by the employer or the doctor. 
 
The role of the guardian of safe working hours (GoSWH) is designed to reassure doctors and dentists in training, and employers, that rotas and working conditions are safe for doctors and patients. 
 
The GoSWH will oversee the work schedule review process and will seek to address concerns relating to hours worked and access to training opportunities.  

The GoSWH supports safe care for patients through protection and prevention measures to stop doctors working excessive hours, and they have the power to levy financial penalties where safe working hours are breached. 

Where the GoSWH can validate such exception reports, the penalties in Schedule 05 of the 2016 TCS will be levied; the fine will be set at the rates outlined in Annex A. 

The GoSWH will convene a doctors’ forum at regular intervals to provide advice on the role and to scrutinise the disbursement of penalty fines. They will provide regular and timely reports on the safety of doctors' working hours, rota gaps and annually on improvement plans to resolve rota gaps to the trust board. This information will be incorporated into the trust’s quality account and made available to the Local Negotiating Committee (LNC), Care Quality Commission (CQC), NHS England, General Medical Council (GMC) and the General Dental Council (GDC). The doctors and dentists' review body may also ask for annual reports on the outcome of work schedule reviews. 

FAQ 39: How does exception reporting work, and how quickly will issues be resolved? 

The process for reviewing work schedules based on exception reports is designed to be agile. Employers need to have an electronic system in place to manage exception reports. 

Doctors should report exceptions where day-to-day work varies from that set out in the work schedule, either in hours of work (including rest breaks) or the agreed working pattern, including the educational opportunities made available. Reports should be submitted and copied to the guardian of safe working hours as soon as possible, and in any case within 28 days. For immediate safety concerns, doctors should follow local processes to report within 24 hours. 

Where exceptions become regular or frequent, a work schedule review will usually be required. 

The process is designed to address issues, so that any subsequent changes put in place as a result of discussion or more formal review can benefit the doctor in post as well as doctors moving into that placement in the future. 
 
Employers should agree on local policies or processes for exception reporting that provide a local framework and process for the submission and review of exception reports in line with the TCS. 

FAQ 40: What systems can we use for the exception reports for the GoSWH? 

There are various software suppliers available who have exception reporting systems. Employers who wish to create their own system are free to do so, and those who do not use either system will need to make their own arrangements.

FAQ 41: What is the GoSWH’s role in monitoring and resolving rota gaps? 

The GoSWH must include data on rota gaps in each quarterly report to the board. A consolidated annual report on rota gaps, together with an improvement plan to reduce identified rota gaps, must be included in the trust’s quality account and shared with the local negotiating committee (LNC). 

FAQ 42: Does the GoSWH have a role in resolving issues around access to education? 

No, the DME will need to resolve any issues around access to educational opportunities that are reported through exception reports.

FAQ 43: How much time should be allocated for the role of guardian of safe working hours? 

As with other supporting professional functions, there is no national standard tariff for the time that should be allocated to perform the guardian of safe working hours role. Employers should ensure allocations are sensible, appropriate, realistic and in keeping with normal job planning guidelines for managerial appointments. In most circumstances, one would expect the time allocation to be the same as that allocated to the departmental head of service or clinical director in the same organisation, although this might be higher or lower depending on the number of doctors in training, the number of and stability of rotas and the amount of administrative support available to the GoSWH. It is important that employers regularly review these arrangements. All GoSWH are encouraged to include any issues around time allocation and/or support for their role in their quarterly board report. 

FAQ 44: What admin support allocation should be made available for the GoSWH in terms of hours? 

The decision on the amount of administration support needed should be agreed locally. Employers need to consider the number of doctors in training, the number and variety of rotas, and the degree of stability in existing working patterns when assessing how much time and support will be needed to carry out the role effectively. We would suggest that arrangements put in place are reviewed regularly to maintain the right level of support. 

FAQ 45: Is the GoSWH responsible in the first instance for all hours and safety issues? 

No, the GoSWH are the champion of safe working hours and are a backstop if normal processes haven’t resolved an issue. The GoSWH should be copied in on all exception reports so that they can fulfil their oversight role and escalate things as necessary. Employers will need to consider what system they have in place for the GoSWH in order to support the administration of the role and the management of exception reports. 

FAQ 46: How should the Guardian of safe working hours (GoSWH) respond if doctors raise questions about pay or other aspects of the contract unrelated to safe working hours?

As GoSWH establish channels of engagement with doctors and dentists in training across their organisations, it is inevitable that they will be asked to comment on aspects of the 2016 contract or on individual employment matters which fall outside of the remit of the GoSWH. It is important that doctors with such questions are advised to discuss such matters with the medical staffing or HR department, or to seek advice from their representative organisation, such as their union. 

FAQ 47: Can the doctors’ forum be convened as a virtual forum?

Yes, where doctors are geographically dispersed, a virtual forum could be an appropriate way of engaging a wider range of doctors in the forum. There are many different versions of webinar and virtual conferencing software that could help to facilitate such virtual meetings.

FAQ 48: Can trusts change the job description?

The published job description is a template and would need to be customised for local use; it is expected that it might therefore be subject to some modification. However, the job description cannot be changed in such a way that the role would no longer meet the description of the role as set out in the 2016 TCS. For example, the job description could not be changed to appoint a GoSWH to only review exception reports that have been filtered by HR/Medical Staffing HR.  

FAQ 49: What role does the GoSWH play for doctors in training who are not on the 2016 terms and conditions? 

Contractually, there is no GoSWH role for doctors who are employed on other terms and conditions. Such doctors may include, for instance: 

• doctors employed on the 2002 contract for doctors in training 
• academic trainees on university terms and conditions, locally employed doctors, and defence medical services trainees on Ministry of Defence (MoD) arrangements. 

However, it is intended that all doctors in training should have access to a GoSWH to ensure safe working hours, so locally, employers may wish to formally extend aspects of the GoSWH role to this group, so as to ensure that the GoSWH and board receive a full picture of how safe working hours are for all of their doctors in training. It is possible that, in some circumstances, by agreement with the LNC, this could include access to some aspects of the system of exception reporting. Where the doctor or dentist in training is substantively employed by another employer or funded by an external party (e.g. the MoD), such arrangements should also be agreed with that employer/funder. 
 
Clarity about these trainees’ access to the GoSWH would be particularly important when preparing the report on rota gaps. Any local policy that extends the GoSWH role in this way would not replace any existing contractual right to rota monitoring for this group of doctors. If this group continued to monitor hours via diary cards rather than exception reports (the most practical and contractually safe solution), then employers would probably need to use the exception reports of the doctors on the 2016 TCS to complement the monitoring data to give a full picture for monitoring purposes. These trainees would have access to the GoSWH if they felt that their concerns were not being addressed via hours monitoring (or other mechanisms), and their monitoring results should also be included in the quarterly GoSWH report. 

FAQ 50: Could the GoSWH also be a SAS doctor? 

The job description and person specification are only a template, and neither the BMA nor NHS Employers have been prescriptive about what grade the GoSWH can be. If employers have SAS doctors, or other members of staff, in their trust who can demonstrate that they will be able to effectively fulfil the requirements of the role, including appropriately challenging more senior colleagues when required, and who can gain the confidence and approval of doctors in training, then the answer is yes and there is no reason why an SAS doctor or other staff member cannot apply for and undertake this role. 

FAQ 51: Guardian of safe working hours - whom can we appoint? 

The GoSWH is not an educational role and should be completely separate to avoid conflicts of interest. The GoSWH should not under any circumstances be the director of medical education (DME) or hold any other role in the organisation’s management structure. When considering someone for the GoSWH role, the employer should consider the time necessary to do the role as well as any issues of duality or possible conflicts of interest. The aim is to recruit someone in whom the doctors and dentists in training can have confidence and who will be able and willing to stand up against the organisation’s management team if necessary. 

FAQ 52: What process should we follow for the appointment of the guardian of safe working hours? 

The following principles should be taken into account in appointing to the role. 

It is the employer’s responsibility to appoint the GoSWH. 

The appointment panel for the GoSWH should comprise the medical director or a nominated deputy, the director of HR/workforce or a nominated deputy, and two doctors in training, nominated by the local negotiating committee (LNC) or equivalent. At least one, and if at all possible, both of the doctors in training must be based in the appointing employer (or host organisation, if appropriate). In exceptional circumstances, where an employer deems it desirable that additional panel members are involved in the interview and decision to appoint, then this should be discussed and agreed with the LNC. 

The panel must reach a consensus on the appointment. 

The recruitment process for the appointment of the GoSWH should otherwise follow local recruitment processes. 

The employer (and/or host organisation, if appropriate) will have discretion to set and allocate the GoSWH’s time commitment, taking into consideration the number of rotas and the number of doctors in training for whom the GoSWH will have responsibility. Such allocations should be sensible, appropriate, realistic and in keeping with normal job planning guidelines for managerial appointments. In most circumstances, one would expect the time allocation to be similar to that allocated to clinical/service line lead roles in the same organisation, although this might be increased or decreased depending on the number of doctors in training, rotas and/or the amount of administrative support available to the GoSWH. 

Employers/host organisations can choose to act collaboratively to make and share the appointment across a number of employers. 

FAQ 53: What happens if the post becomes temporarily vacant in the future? 

At points, it is likely that there may be short periods of time when the GoSWH role is vacant. In such cases, employers/host organisations will need to put an interim arrangement in place to ensure that the role of the GoSWH can be temporarily covered until a substantive appointment can be made. These temporary arrangements should be agreed with the local negotiating committee (LNC). 

Where trusts are finding it difficult to attract applicants to the role, they may want to consider contacting their neighbouring trusts for advice, widening the role to other staff groups, and/or reviewing the remuneration package and time allocation on offer and /or ensuring that there is appropriate administration support for the role.  

FAQ 54: Who will be the Guardian of Safe Working Hours (GoSWH) for GP trainees for the period that they are in their general practice placement and not in a hospital? 

Where lead employer arrangements exist, the lead employer will be responsible for ensuring that there is a GoSWH appointed for all doctors in training, including GP trainees. GP practices and the lead employer should work in partnership to ensure arrangements are in place which facilitate this arrangement. Where no such lead employer arrangements are in place, it will be for the employer (the GP surgery) to identify and appoint an appropriate person to act as the GoSWH, in line with the requirements of the 2016 contract. The terms and conditions of service (TCS) set out provisions for the appointment of GoSWHs where an employing organisation has fewer than 20 trainees. 

FAQ 55: Do fines for 5-hour and 8-hour rest breaches occur in the case of one single breach, or will they be dependent on averages? 

The fine is applied to a breach of the core rest limit and concerns arrangements around safe working in the shift immediately following the NROC where the rest breach occurs (see provisions in Schedule 3, paragraphs 31-33 of the terms and conditions of service). It is a measure to ensure that doctor and patient safety are not compromised. These breaches shouldn’t be happening on a regular basis, and if they are, that’s an indicator that review of the pattern is needed to look at the root causes and to put measures in place to avoid recurrent breaches.