Exception reporting reforms - preparing for implementation

• Provide a summary of changes to 2016 terms and conditions of service (TCS) England.
• Provide access to supporting guidance, with additional guidance necessary to describe the implications for lead employer organisations.
• Issue a project plan to deliver change in local processes and action a cultural shift in supporting exception reporting if required
• Consider comms and engagement plans covering:
  • the medical workforce
  • rota co-ordinators
  • finance team.
• Create an investment risk plan.
• Explore interactions with NHS England's commissioned board lead for improving doctors working lives (IDWL).

• Undertake a review of capacity and undertake any recruitment to meet increased admin requirements.
• Review team structures to identify areas of potential conflict with changes (HR involved in the exception reporting process should not be co-located with the clinical workforce).
• Identify local education and training gaps and consider improvement activities.
• Determine the process for sending exception reporting information to payroll for payment.
• Review work schedules to ensure they meet contractual requirements and minimise the opportunities for exception reporting – continue current responsibilities. Strengthening work schedules to manage doctors in training and service expectations would have a tangible impact on compliance, engagement, and efficiency. Additionally, ensure that all work schedule rota patterns have clear names to associate with exception reports on the system.
• Formalise budgets to cover the cost of any breaches.
• Review recruitment/induction processes to ensure this is proactively managed to allow access within seven days of starting.
• Lead unit organisations to review Lead Unit Business Agreement arrangements.
• Undertake a review of relevant trust policies and procedures.
• Work schedule compliance and financial sign off process confirmation.

Employers need to give effect to the updated national TCS locally. Employers are required to write to all affected staff (trainee doctors and dentists and to those who exception reporting access has been extended locally) informing them of the changes to their contractual terms, following agreement under national collective bargaining arrangements.

• Generate a list of all eligible employed doctors and dentists in training (and those who the provisions have been extended locally) (residents), their contract type and grade using ESR within a month of major rotation dates and complete cross validation with a list of doctors and dentists with access to exception reporting systems.
• Review LED workforce - locally employed doctors whose terms of employment substantively mirror the 2016 TCS.
• Agreements to be reached with the local negotiating committee (LNC) (or equivalent where no LNC exists).
  • Over 2 hours additional work – ‘subject to locally determined process’ in addition to the under two hours process.
  • LNC agreement for when access to exception reporting is not possible for reasons outside of the employers’ control.
  • Arrangements for GoSWH delegation and deputising and agreeing alternative arrangements if an employer is unable to appoint a GoSWH.
  • Arrangements for DME delegation and deputising.
  • Local management of new fines structure - penalties/fines and their disbursement; access/completion fines and proven information breach fines.
  • Quarterly report sharing arrangements.
  • Local monitoring of revised processes.

As per the inform the board section, plus:

• Review GoSWH role, fill any vacant positions and refine the level of administrative support considering the new requirements.
• Confirm the GoSWH deputising arrangements to ensure consistent access to the GoSWH function.
• Confirm the DME deputising arrangement to ensure consistent access to the DME function.
• Review and update job plans (mutually agreed) of those affected by the changes (covering the GoSWH, GoSWH deputy, educational and clinical supervisors)
• Explore opportunities to support and deliver cultural changes as necessary to secure the benefits of exception reporting (ie, introduce necessary changes to minimise the need for exception reporting). Departmental leads and deputies.

What is required: 

• summary of changes to TCS, access to supporting guidance, project plan to deliver change in local processes, comms, and engagement plan to medical workforce.
• Seek support in communicating changes to the medical workforce.
• Update relevant policies and procedures regarding the handling of detriment.
• Update departmental induction processes for new resident doctors and dentists.

• Detail changes to role; access to updated guardian resources when republished (existing resources available here: Information for guardians of safe working hours | NHS Employers).
• Review and update GoSWH job plan (mutually agreed).
• Review the level of admin support and responsibilities. A business case may be required to make the case for additional resources to support the new arrangements.
• Confirm deputising arrangements to ensure consistent access to the guardian function.
• Communicate changes in the GoSWH role to medical workforce; to include escalation/remediation pathways.
• Consult with HR/Medical staffing on changes and new ways of working.
• Cross-validate all eligible employed residents against a list of doctors and dentists with access to exception reporting systems (within one month of the major rotation dates).
• Confirm data sources to help inform the analysis of exception reporting reports. Data used will need to be underpinned by a governance framework to provide assurance that it represents a reliable source of information.
• Update the GoSWH quarterly and annual reports to the Board, the content of which will need to include:
  • summary of reports submitted
  • safe working hour breaches
  • missed break breaches
  • information breaches
  • ‘access and completion’ breaches
  • all rota gaps on all shifts
  • detriment and perceived detriment (collected via survey) experienced by doctors in relation to exception reporting.
• Levy fines where necessary; confirm how the accumulation and disbursement of fines will operate, underpinned by appropriate governance arrangements; create and manage GoSWH fines account (new and existing) and distinct sub-accounts (to enable more granular distribution).
• Determine the arrangements to regularly survey residents re: experiences of detriment; survey on a quarterly basis. The survey will include the new access and completion to exception reporting system, and information breach fines.
• Review submitted exception reports to highlight trends/patterns.
• Mandate award of TOIL when necessary.
• Confirm software provider implementation plans and supporting training resources, where applicable. 

• Detailed changes to role; access to updated DME guidance
• Review and update DME job plan (mutually agreed)
• Confirm deputising arrangements.
• Communicate changes in role to medical workforce; to include escalation/remediation pathways.
• Consult with HR/medical staffing on changes and new ways of working.
• Establish a trust approach to common exception reports (such as missing protected training), proactively identifying themes from early reports and act on them.
• Report to the trust board quarterly or annually (as appropriate) on education exception reports, via the medical director and/or other locally agreed processes via verbal or written report.

What is required:

• Summary of changes to TCS, access to supporting guidance, project plan to deliver change in local processes, comms, and engagement plan to medical workforce.
• To be informed of their removal from process and associated systems unless consent is provided by the doctor.
• Review and update job plans (mutually agreed) in accordance with contractual provisions.
• Engagement to deliver local induction information to resident doctors and dentists.
   

• Summary of changes to TCS, access to supporting guidance, to confirm handling of TOIL and supporting processes in line with required confidentiality restrictions.
• Develop/update local how to run the rota guide to support rota co-ordinators.
• Maintain all rotas and ensure that they are accurately labelled/named; the work schedule name should correlate to the exception report names.

• Determine appropriate budget holders for all costs associated with exception reporting.
• Understand new exception reporting validation processes and audit requirements.
• Confirm exception reporting information confidentiality requirements.

• Understand new exception reporting validation processes and audit requirements.
• Confirm ER information confidentiality requirements; review scheme of delegation and necessary budget reports.
• Create new budget codes to enable the payment of any fines applied.
• Determine arrangements to allow for a more granular disbursement of fine money eg, create new GoSWH sub accounts.

• Understand new exception reporting validation processes and audit requirements.
• Determine process for relevant payments to be made to doctors or dentists because of exception reporting, with appropriate confidentiality protections.
• Confirm payroll cut-off/submission deadlines for payments to be made so that this information can be relayed to doctors and dentists.

Fine calculation is complex and will need to be monitored to ensure payments made are correctly applied.

• Understand new exception reporting validation processes and supporting audit requirements. 

• Understand new exception reporting validation processes and supporting audit requirements.
• Confirm ER information and confidentiality requirements.

• Understand new exception reporting validation processes and supporting audit requirements.
• Review self-declaration requirements to ensure that the information submitted by a resident adheres to the reasons for exception reporting is accurate and to the best of the doctors/dentists’ knowledge.

• Lead employers will additionally have to talk to their host organisations to confirm ways of working to be confirmed:
  • GP and host employer comms – review current working arrangements/memorandum of understanding; confirm list of contacts.
  • Involvement of Integrated Care Board for GP settings to be considered.
• Confirm process for accessing central funds (NHSE to determine) and associated timescales (from 4 February 2025)
• Understand expectations regarding a review of working practices in non-hospital/community settings i.e. what action should be taken considering exception reporting. 

• A list of all eligible employed residents, their contract type, grade and salary must be generated by HR/medical staffing from Electronic Staff Record data (ESR) within a month of major rotation dates and circulated to the GoSWH for cross-validation with a list of doctors and dentists with access to exception reporting systems. For those groups outlined in the scope, RDI encourages information to be provided for onboarding to this process, e.g. through addition to ESR.

• Review and update the induction processes and associated training for new starters to reflect changes in exception reporting processes. This should also include details of:
  • how TOIL will be managed – this will require the engagement of clinical teams and the GoSWH to confirm details of the process (as set out in the Managing TOIL section).
  • the use of existing local grievance processes for raising concerns.
• Emphasis at induction should be about encouraging exception reporting and adoption of collaborative approaches to rectify any non-compliant working arrangements.

• Employers will be instructed to provide access to residents within seven days of starting work, changing work site, employer, or any other related transition.
• Access should be validated by submission of a ‘test’ exception report within those seven days, monitored by the GoSWH and their deputies.
• Residents must not be prevented from completing exception reports due to issues with the system, such as errors regarding incomplete rotas or unlisted data.
• Where rotas are a required selection in the process of exception reporting, the specific name of the relevant rota on the exception reporting system must be listed within a doctor’s work schedule.
• Residents must be provided with a simple way (such as email or quick access link) to raise to the GoSWH and HR after the initial seven days of starting work, changing work site, changing employer, or any other related transition, if they are unable to access the ER system or complete, an exception report. If problems with accessing or completing an exception report are not remedied within seven days of being raised, the GoSWH must levy a fine as outlined in the fines section below. Fines will then be payable by the responsible party listed below on a recurring seven-day basis until the issue is resolved.
• For residents working with host employers, their lead employer will carry the responsibility for provisioning the exception reporting process and for any fines incurred as a result. Where residents work across multiple employers, their substantive employer will carry this responsibility, except in cases where the substantive employer is non-clinical, e.g. university employees, in which case the clinical employer will carry this responsibility. DHSC Will be writing separately to lead employers to confirm the recharging arrangements to cover the cost of exception reporting in non-hospital settings.
• Associated fines to accumulate as a central single pot. Disbursement will be made more flexible, with a focus on initiatives that enhance residents’ wellbeing.
• Money paid to the GoSWH fund will not be paid directly to doctors or dentists.
• Existing penalty rates paid to doctors and dentists will be maintained.
• Existing accumulated fines via the 2016 TCS will carry over to the GoSWH’s single pot (Hourly Penalty Rates paid to doctors under Schedule 02 Paragraph 77 and Annex A of the 2016 TCS will be unchanged. Hourly GoSWH Fines under Schedule 02 Paragraph 77 and Annex A of the 2016 TCS will accrue at a granular level unless affected doctors and dentists choose otherwise).

• Exception report submission by doctor.
• Cross-checking of evidence by HR/medical staffing.
• Escalation to confirm the validity of the claim, where necessary.
• Withdrawing from the process, handling rejections.
• Payment/TOIL confirmed.
• GoSWH to review reports to highlight trends/patterns.

ER data must be treated as confidential and cannot be accessed, shared, or requested to be shared beyond specific pathways listed in this framework and subsequent guidance without a resident’s freely given consent. Proven violations will be subject to an information breach penalty.

• Ensure information flows are mapped out and secure.
  • Identifiable data for educational exception reports can only be shared with the DME and their deputies and, at the academic trainees’ discretion, a nominated academic supervisor. If remediation of an educational opportunity is possible, the DME will share further information as required for that purpose with the resident's consent.
  • Identifiable data (specifically identifying the individual) related to the number or content of exception reports for additional hours worked may only be shared to or accessed by appropriate HR signatories, GoSWH, their nominated deputies and payroll, unless specifically detailed in a pathway elsewhere in this framework.
  • Non-identifiable data derived from exception reporting may be shared for audit and financial purposes with appropriate recipients. Identifiable data, explicitly excluding the exception report number or content, (for example salary) may be used for normal financial management and audit processes and will not be constrained. There are no restrictions on access to those whose job roles are related to professional auditing.
• A list of individuals with direct access to a doctor’s exception reporting data must be communicated to the doctor by email at onboarding, and when new individuals are granted access.
• Extract data from ESR on a regular basis that captures all those doctors and dentists with access to the exception reporting system.
• ‘live’ rosters access for HR and GoSWH where feasible.
• Details concerning the interaction of exception reporting information and work schedule reviews in noted under the Work Schedules Review section.

Residents must be provided with the identity of the individuals with access to exception report derived data at their request co-ordinated by HR/medical staffing. 

• Identifiable data (specifically identifying the individual) related to number or content of exception reports for additional hours worked may only be shared to or accessed by appropriate HR signatories, GoSWH, their nominated deputies and payroll.
• Exception reporting data can only be accessed, shared, or requested to be shared beyond this list with the resident’s consent. Proven violations will be subject to information breach penalty.
• Non-identifiable data derived from ER may be shared for audit and financial purposes to appropriate recipients. Identifiable data, explicitly excluding the exception report number or content, (for example salary) may be used for normal financial management and audit processes and will not be constrained. There are no restrictions on access to those whose job roles are related to professional auditing.

All residents must receive their choice of either payment or TOIL for all time worked above contracted hours following an exception report, except when a breach of safe working hours mandates the award of TOIL.

HR/medical staffing are required to cross-check evidence in support of a claim for additional hours worked and if the information provided is accurate, they will send information to payroll for processing or approve TOIL.

The supporting process is set out below and will be managed by the doctor/dentist and the clinical team and where necessary the GoSWH. 

• When a resident elects to receive TOIL, or TOIL is mandated by the GoSWH, an award of TOIL must be communicated electronically to the resident (this may be possible via software functionality).
• The resident will then select an appropriate member of their clinical team to share that communication and enable TOIL to be taken. TOIL must be arranged (that is booked and agreed) within one day of award if mandatory, and 10 days of award if requested.
• The resident may escalate to the GoSWH for remediation if these time limits are breached, or if agreed TOIL is not facilitated.
• After taking TOIL, the resident must record its completion.
• In those cases where TOIL must be taken immediately to protect patient safety, for example following an overnight breach of safe working hours, residents will directly contact their clinical team, who must facilitate the award. The resident should subsequently record the exception for GoSWH review.

Residents must not be discouraged from submitting exception reports and should not suffer detriment because of engaging with exception reporting processes.

The GoSWH will oversee quarterly surveys that include details of any actual or threatened detriment, with results included in the quarterly GoSWH reports.

For residents working in small departments or in community settings, such as GP registrars, the collection and disbursement of fines, payment for additional hours worked and guidance around rostering, should be implemented to allow improvement of residents’ working practices by employers, without breaching confidentiality or risking detriment to residents.

• Review current policies and procedures considering the changes to exception reporting processes.

Confirmation of processes to ensure payment of fines to doctors and dentists covered by the exception reporting rules, with breaches incurring a financial penalty listed in Schedule 5 paras 22-23. Fines for any other purpose will not be paid directly to doctors or dentists.

The resident will be paid for the additional hours at the penalty rates set out in the relevant Pay and Conditions Circular (M&D) (2/2025 is the version that currently holds this information)

• Information detailing the breaches that have occurred and incur a fine will need to be secured via the GoSWH to inform payroll.
• Details of the fines will be published in the organisation’s annual financial report (accounts), including those paid directly to doctors and dentists. Details of how the fine money has been spent will also need to be included in the GoSWH's annual report.

A work schedule review can be triggered by one or more exception reports, or by a request from either the doctor or the employer. A work schedule review should consider safe working, working hours, educational concerns and/or issues relating to service delivery.

Where a doctor, an educational supervisor, a manager, or the GoSWH has requested a work schedule review, consent must be sought from the doctor or dentist to share personally identifiable information derived from their exception reports.

In instances where a systemic issue related to the doctor’s work setting is identified but consent has not been secured from the doctor, the GoSWH may choose to initiate a level 2 work schedule review (as set out in the 2016 TCS). This will ensure work schedule reviews can be initiated whilst maintaining the confidentiality of personally identifiable information.