HR clarification of additional hours worked exception reports
What is exception reporting and who it applies to
Exception reporting applies to all doctors and dentists in training (referred to collectively hereafter as ‘the doctor’) who are substantively employed under the Terms and Conditions of Service for NHS Doctors and Dentists in Training (England) 2016 (2016 TCS) and to those whom the provision has been extended locally. It is recognised that the 2016 TCS are widely mirrored in other employment contexts, and we encourage employers in England to make every effort to extend exception reporting where appropriate*.
The purpose of exception reporting is to ensure prompt resolution and / or remedial action to ensure safe working hours are maintained, secure patient safety, and safeguard the delivery of agreed educational opportunities. Exception reporting is also the mechanism used by doctors to ensure compensation for all work performed and uphold agreed educational opportunities.
This exception reporting guidance is intended to provide direction and advice on how to interpret and implement the changes to exception reporting being enacted via version 13 of the 2016 TCS. This guidance seeks to provide recommendations and best practice approaches to implementing and adhering to these changes.
The overriding principle of these changes is to trust doctors to conduct themselves professionally, and to remove previously existing barriers to exception reporting.
* For example: Academic trainees who hold a national training number/deanery number and are substantively employed by universities. For these doctors, it is encouraged that their exception reporting provision should be extended by clinical employers through a standardised contract. Armed forces trainees who hold a national training number/deanery number. Public health trainees. Locally employed doctors whose terms of employment substantively mirror the 2016 TCS. Locally employed doctors whose terms of employment do not substantively mirror the 2016 TCS, but to whom ER has already been extended at a local level by their employers.
Purpose of the HR clarification stage
When an exception report relating to additional hours worked contains incomplete information, inconsistencies, or missing evidence, HR must undertake a clarification process before approval or rejection. The purpose of the clarification stage is to ensure that the exception report contains the complete, accurate and verifiable information required under Annex D before any decision regarding payment or time off in lieu (TOIL) is made.
Method of contact
HR must contact the doctor via their NHS email or through the exception reporting software, depending on the system the organisation uses.
All communication must be:
- written
- clear and specific
- retained as part of the audit trail for the report
- conducted in line with the confidentiality requirements relating to exception reports.
No clarification should be sought verbally, unless the doctor specifically requests a call, and even in those cases HR or the doctor must follow up in writing to document the request and the information exchanged.
HR must not contact the doctor’s department, supervisors, or GP practice during this process as this would be an information breach.
Content of the HR clarification request
The clarification request will set out:
- The specific inaccuracy or missing information identified in the exception report.
- Why the additional information is required, with reference to Annex D evidence standards where applicable.
- What evidence or clarification the doctor needs to provide, such as:
- confirmation of the scheduled/actual start or finish time
- providing the live rota information
- confirming if a swap or duty change has occurred which was unclear in the evidence submission
- upload of the required electronic date/time/location evidence
- confirmation of the preferred outcome (payment or TOIL).
The HR clarification request will not ask for justification as to why the additional hours were necessary.
The doctor should provide the information requested, either through the exception reporting software platform or by replying via email at the earliest opportunity to avoid any delay in progressing. This clarification period will not count towards the 7/10 calendar day response time in the 2016 TCS.
Support and guidance provided to the doctor
HR should provide clear guidance to support the doctor in resolving the issue. This may include:
- a brief explanation of the relevant Annex D requirement (for example evidence needed for compensation to be approved)
- a link to local guidance on how to upload evidence through the software
- a reminder that the doctor can seek advice from their guardian of safe working hours if unsure of how to proceed
- where evidence cannot be submitted through the reporting software, HR should remind the doctor that it can be submitted via email, as required by the 2016 TCS.
Process following clarification contact to doctor:
Timeframes and escalation
- HR should aim to complete the clarification stage promptly, and no later than seven calendar days (10 calendar days until 4 August 2026) after receiving the exception report.
- If the doctor provides the requested information, HR should confirm receipt and proceed to approve the report without unnecessary delay.
- If the doctor does not respond, HR should send a reminder email after seven calendar days.
- If no response is received after reasonable notice, accounting for mitigating factors (for example leave) then the report will be rejected and closed. A doctor may escalate to HR or the GoSWH hours for remediation if they believe that their exception report has been unfairly closed.
Record keeping
The doctor should, wherever possible, attach the evidence to the exception report upon submission. Where feasible, HR should ensure that all clarification communication is saved within the exception reporting system, or uploaded to it, forms part of the report’s audit trail, is available to the GoSWH upon request, and is retained in line with the 2016 TCS requirement for retaining all exception reports, including withdrawn ones.
Maintaining a full audit trail ensures transparency and assists the GoSWH in monitoring organisational compliance.
Nature of communications
All communications must be neutral in tone and free from any language that discourages the doctor from reporting exceptions. The aim is to clarify factual information rather than question the doctor’s judgement or the merits of the report. HR staff must ensure that their approach reinforces the principle that doctors should feel confident to exception report.
Managing inaccurate reports
The clarification process aims to ensure accuracy, fairness, and safe working practices.
Deliberate falsification or misconduct would trigger a separate HR or professional conduct process. The doctor will confirm via self-declaration that the information they are submitting adheres to the reasons for exception reporting as set out in paragraph 12 and is accurate and to the best of the doctors’ knowledge (Schedule 5 paragraph 9).
If inaccuracies are repeated or appear systemic, HR should notify the GoSWH, for them to investigate in accordance with the process set out in Schedule 6, paragraph 13.
