Exception reporting guidance for HR and medical staffing

Roles and responsibilities

HR/medical staffing

HR / medical staffing will action all additional hour exception reports, which are claims of less than two hours. Following local agreement with the local negotiating committee (LNC), with input from the resident doctors forum (RDF), the responsibilities assigned to HR within the 2016 TCS can be allocated to alternative departments/staff (for example GoSWH deputies/assistants). This is to recognise that there will sometimes be need for flexibilities to accommodate local circumstances, and not to arbitrarily prevent working local processes. If this occurs, all the duties of HR staff in relation to exception reporting set out within the 2016 TCS, must be allocated to these alternative staff.

The guardian of safe working hours (GoSWH) 

The GOSWH will review the outcome of the exception report to identify whether further improvements to the doctor’s working hours are required. The full scope of the GoSWH role can be found in detail in Schedule 06 of the 2016 TCS.

The director of medical education (DME) 

The DME will review the outcome of the educational exception report to identify whether further improvements to the doctor’s training experience are required. 

Onboarding

The employer must provide access to exception reporting for a doctor within seven calendar days of them starting employment or work, and then subsequently whenever a doctor changes host employer, work site, or rota (as per Schedule 05 paragraph 18 of the 2016 TCS). 

The doctor must action a test exception report, which will be sent to the GoSWH for cross-validation (as per Schedule 05 paragraph 18 of the 2016 TCS). The cross-validation can be done by generating a list of all eligible resident doctors, their contract type and grade using ESR and completing a comparison with a list of resident doctors with access to exception reporting systems.

Employers should give consideration to those within the scope of exception reporting who start outside of the main rotation dates and ensure appropriate processes are in place.

What can be an exception report

The activities to which exception reporting applies are listed in Schedule 5, paragraph 2 of the 2016 TCS.

HR/medical staffing will action exception reports related to additional hours worked only. The following categories will be sent to the GoSWH for oversight, action or reporting purposes:

• the inadequacy of clinical support
• the inadequacy of rostered skills mix
• raising concerns of a suspected non-compliant rota pattern
• detriment or threat of detriment related to exception reporting
• information breach
• access and completion test   
• the inability to take contractual breaks (in instances where they do not reach the limit that would incur a fine).

Missed educational opportunities will go to the DME for review. A doctor cannot receive payment twice for the same shift. Therefore, if clinical duties are performed during scheduled educational time, no additional payment should be issued. Instead, an educational exception report will be raised. While every effort must be made to ensure delivery of remediation during their scheduled hours, it may be necessary, with the agreement of the doctor, that the educational activity is reinstated in non-working time.

In such cases, an additional hours exception report should also be submitted to capture the additional hours worked and linked to the original educational exception report.

It should be made clear within the report when additional hours were worked as part of the reinstating of educational activity, and consideration must be given to ensure safe working hours are maintained.

Breaks are paid time for doctors and dentists in training; there will be no payment for missed breaks. All exception reports for missed breaks will go to the GoSWH, who will levy a fine if breaks are missed on at least 25 per cent of occasions across a four-week reference period. 

HR/Medical staffing sign-off process

The full process is set out in Annex D of the TCS.

This process must occur for all exception reports related to additional hours worked for up to two hours in any one occurrence. Exception reports for more than two additional worked hours should be subject to a locally determined process, which must be agreed upon with the LNC. As per Schedule 05 paragraph 13, exception reports for more than two additional worked hours should be subject to a locally determined process, which must be agreed upon with the staff LNC. These should be investigated to ensure safe staffing is maintained, and this process and outcome will not be subject to an information breach fine. This process should be at a minimum, more extensive than the under two-hour process. 

HR must review the exception report, cross-check the information required below for accuracy within seven calendar days (10 days until 4 August 2026).

The following three items will be cross-checked:

• Mandatory fields outlined in Schedule 05 paragraph 14.
• The doctor’s live rota. Current rota information must be accessible to the actioner for these checks.
• Electronic evidence of time, date and location of the occurrence (eg a timestamped location). If a doctor cannot provide electronic evidence, corroboration by another regulated clinical professional may be accepted as per Annex D paragraph 11 of the TCS.
  • For non-resident on-call (NROC) shifts, evidence of time and date may be required as described in jointly produced guidance. Within seven calendar days (10 calendar days until 4 August 2026) of receiving an exception report, HR must cross-check the three items above for accuracy, and if accurate, approve the report for payment, unless TOIL has been requested or is required to address safe working hours.

HR is not expected to investigate the circumstances surrounding an, exception report and should not contact third parties in relation to a submitted exception report. HR communications with doctors and GoSWH are not intended to replace the previous activities of an educational supervisor.

If any of the three items listed above are missing or inaccurate, the HR clarification stage is triggered.

Mandated TOIL

For approved exception reports, the doctor must receive their choice of either payment or TOIL for all time worked above contracted hours, except when TOIL is mandated.

The doctor has a professional responsibility for ensuring that their total hours of work comply with the contractual and regulatory limits set out in Schedule 3 of the 2016 TCS. 

Audit and safeguarding public funds

For each exception report the doctor will confirm that all details are accurate via a self-declaration as outlined in the 2016 TCS, Schedule 05, paragraph 9, alongside their submitted evidence. Local policies also apply, such as fraud and grievance processes, which doctors should be made aware of at induction.

If employers choose to implement local variations to these requirements, they must ensure that any alternative processes remain compliant with Standing financial instructions (SFI). SFIs are designed to ensure that financial transactions are carried out in accordance with the law and government policy in order to ensure probity, accuracy, economy, efficiency and effectiveness. 

Handling of exception reporting information

Exception reporting data must be treated as confidential and cannot be accessed, shared or requested to be shared without the doctor’s explicit consent, outside the specific pathways listed in the TCS and in jointly produced guidance.

Doctors' and dentists' responsibilities