2. Recommendations (Note, Approve, Discuss) The main outline of the report is for noting and discussion as appropriate.

Transcription

1 Report to: Public Board of Directors Date of Meeting: 14 December 2016 Agenda item: 10 Title of Report: Status: Board Sponsor: Author: Appendices A. Implementation of the New Junior Doctor Contract B. The New Role of Guardian of Safe Working C. Governance/structures Supporting Junior Doctor Education and Training For Information Dr Tim Craft, Medical Director Sue Davis, Head of Human Resources Clare Heath, HR Business Partner Dr Fenella Maggs, Guardian of Safe Working Dr Illana Langdon, Director of Medical Education Appendix 1 - Summary of Rotas Appendix 2 NTS Trainer Questions 1. Executive Summary of the Report The report sets out an overview of the current status of the national implementation of the junior doctors contract across the Trust. It includes an update from the Guardian of Safe Working and the Governance/structures Supporting Junior Doctor Education and Training 2. Recommendations (Note, Approve, Discuss) The main outline of the report is for noting and discussion as appropriate. 3. Legal / Regulatory Implications There are no legal or regulatory implications regarding the implementation of the new contract. The GMC mandates a clear educational governance structure within each trust. 4. Risk (Threats or opportunities, link to a risk on the Risk Register, Board Assurance Framework etc.) Currently, no risks have been identified on the risk register regarding the implementation of the new contract, however, it is acknowledged that this will be reviewed in liaison with the Medical Workforce Planning Group as required. Any potential risks will be identified from the phased contract implementation timeline as agreed nationally. Risks identified relate to patient safety, as identified already on the HESW Quality Risk Register and to risk of withdrawal of trainees in unsatisfactory placements. 5. Resources Implications (Financial / staffing) The financial implications on the implementation of the contract for all junior doctors in training across 38 rotas currently is being reviewed. Agenda Item: 10 Page 1 of 13

2 6. Equality and Diversity An equality impact assessment for the contract implementation has been attached for information. 7. References to previous reports Updates on the junior doctor s contract implementation have been highlighted during the project implementation group which is held monthly and the Medical Workforce Planning Group. 8. Freedom of Information Public involves public finance Agenda Item: 10 Page 2 of 13

3 A. Implementation of the New Junior Doctor Contract B. The New Role of Guardian of Safe Working C. Governance/structures Supporting Junior Doctor Education and Training 1. Purpose The junior doctors contract implementation, following negotiations with the British Medical Association (BMA) became live from 3 rd August 2016 and to ensure guidance and an operational framework is in place to support the transitional arrangements a Project Operational Implementation Group was formed in May 2016, which reports to the Medical Workforce Planning Group, Chaired by the Medical Director. The below provides an overview to date:- 2. Guardian of Safe Working The Trust has appointed Dr Fenella Maggs, Consultant as Guardian of Safe Working in line with the Terms and Conditions of Service 2016 (TCS), key responsibilities include:- Champion of safe working hours. Provide assurance on safe working and compliance with TCS. Oversee safety related exception reports and monitor compliance. Escalate issues for action where not addressed locally. Intervene to mitigate safety risks. Require work schedule reviews to be undertaken where necessary. Distribute monies received as a result of fines for safety breaches. Administration support arrangements are in place on a 12 month fixed term contract to support the Guardian of Safe working and HR Project Support Officer in implementing the new Junior Doctor contract and a Guardian of Safe Working e mail has been set up. The administration post holder is responsible for administering the electronic rostering systems (DRS) for monitoring doctors' hours and paying them correctly. 3. Project Operational Implementation Group The Project Operational Implementation Group for the junior doctors contract has been in place since 26 th May 2016 and provides assurance to the Medical Workforce Planning group (MWPG) regarding the effective roll out and implementation of the 2016 new contract arrangements. 4. Implementation The TCS went live on 3 rd August 2016 and the first staff group to transition to the new terms was Obstetrics ST3+ effective from 5 th October 2016 which impacted 9 trainees who already were employed by the Trust. Agenda Item: 10 Page 3 of 13

4 In line with the national implementation timeline the next group and training programme to transition across is the F1 Medicine/Surgery and MAU affecting 36 junior doctors. Appendix 1 outlines the key dates for implementation and the current situation with rota compliance. Work is ongoing to assess the potential financial impact of the contract, but it is anticipated the pressure will be hundreds as opposed to tens of thousands of pounds when quantified. To ensure that the implementation timelines are achieved fixed term contracts have been issued to junior doctors as appropriate, which enable the Trust to transition the junior doctors to the new contracts in line with the national timescales. 5. Exception reporting and work schedule reviews All junior doctors on the 2016 TCS and all Educational Supervisors and Clinical supervisors will have access to DRS. The Exception Reporting and Work Scheduling Review Protocol has been finalised and has been uploaded on to the Trust s Junior Doctors web pages. The agreed protocols mirror the national guidance and enables the trust grievance procedure to be invoked in the event that work schedule review need to be progressed It is the intent that the Educational Supervisor will liaise with either the Director of Medical Education (DME) in relation to training issues or to the Guardian of Safe Working Hours for concerns regarding safe working practices. To date there have been no exceptions or requests for work schedule reviews. 6. Equality Impact Assessment An Equality Impact Assessment has been completed as in line with the national implementation guidelines. The assessment has been disseminated to the Operational Project Group, Deputy Director of HR (delegated lead for equality); Director of Medical Education, Guardian of Safe Working, MWPG and the Champion of flexible working with feedback pending from junior doctor representatives. 7. Doctors Rostering System The Trust currently uses the Skills for Health Doctors Rostering system (DRS) 4 and junior doctors when transitioning across to the new TCS are issued a user name and password to enable them to escalate any exceptions. These details are provided with the agreed work schedules 8 weeks prior to the junior doctors commencing on the new TCS. Agenda Item: 10 Page 4 of 13

5 Currently DRS is being further developed following feedback from the initial training session held by Skills for Health and will be finalised for the December transition of F1 junior doctors. 8. Electronic Staff Record Programme (ESR) ESR has been upgraded to accommodate the contractual payment elements of the TCS and all associated paperwork and processes modified to accommodate the changes on transition and pay protection aspects. 9. The New Role of Guardian of Safe Working Dr Maggs has been in post as the Guardian of Safe Working since 3 rd August She attended a Guardian of Safe Working Hours event run by NHS Employers in July. The summit involved briefings, group discussions and a panel Q&A involving colleagues from NHS Improvement, Health Education England, Care Quality Commission and the BMA Junior Doctors Committee. She learnt about the new contract and the Guardian role, and met many fellow Guardians. A Guardian of Safe Working Hours forum for Guardians in the South-West has been established to support practise sharing as the role develops. Dr Maggs has been to Exception Reporting Training held by DRS (software provider for rota design and exception reporting at the RUH), and was able to contribute to the development of the exception reporting software. 9.1 Progress Dr Maggs has been raising awareness of the new contract and its implications by for example, attending junior doctors inductions to introduce herself and the new contract in August. She gave a presentation to Educational Supervisors at their 2016 Annual Trainers Update for Health Education England South West in September and has written an intranet webpage ( with a link on the Junior Doctors home page ( Work schedules for all doctors who have moved or are shortly to move onto the new contract have been developed and distributed. The contract specifies that a member of the educational faculty is designated as a champion for flexible training. Dr Kate Peacock has agreed to take on this role. The new contract also dictates that a Junior Doctors Forum be set up. Such a forum was already in existence at the RUH, but under the terms of the new contract the forum has to include junior doctor representatives from the LNC as well as the Chair of the LNC, and relevant educational and HR colleagues. Agenda Item: 10 Page 5 of 13

6 The first meeting was held on 18 th November, and it was attended by Dr Tim Craft (Medical Director), Miss Ilana Langdon (Director of Medical Education), Dr Simon Malthouse (Local Negotiating Committee representative), Dr Hamad Parwaiz (BMA Trainee representative), Angela Hayday (Associate Director of Organisational & People Development), Jan Lynn (Lead Nurse), as well as a good turnout from the junior medical staff. 9.2 Doctors transition to the new contract As of 5 th October 2016 nine Obstetrics and Gynaecology Registrars have moved onto the new contract, without any complications. 9.3 Exception reporting There have been no exception reports raised to date. 9.4 Future challenges The 36 F1s at the RUH move to the new contract on Monday 5 th December They have all been sent their new contracts and work schedules. Dr Maggs has been in contact with all F1 Educational Supervisors, Dr Mark Mallet (Rota Coordinator for F1s) and has talked to several F1s to assess their current rota compliance. Very few concerns have been raised, and any issues that have been raised are being resolved before the doctors move onto the new contract. It is expected, however, that the F1s will raise exception reports, though the impact of these is difficult to predict. There may be financial penalties to be paid, and if there are significant or regular breaches to the doctors working hours, rotas may need to be altered. Another potential challenge may be the extra work that exception reporting causes for Educational Supervisors (who, according to the contract, have to maintain overall responsibility for signing off exception reports, although this can be delegated to e.g. Clinical Supervisors, or other Consultants). The Director of Medical Education and the Guardian will monitor this closely as exception reports start to be raised. 10. Governance/structures Supporting Junior Doctor Education and Training 10.1 Proposed Educational Governance Structure for RUH Bath NHSFT The GMC has advised a formal structure to be in place for educational governance. The following structure has been developed for the RUH. Agenda Item: 10 Page 6 of 13

7 10.2 GMC Trainer Survey - Results for Trainers on GMC National Training Survey 2016 Local Education Provider Green Red Ratio of Outliers Outliers Green/Red Gloucestershire Hospitals NHS Foundation Trust Great Western Hospitals NHS Foundation Trust North Bristol NHS Trust Northern Devon Healthcare NHS Trust Plymouth Hospitals NHS Trust Royal Cornwall Hospitals NHS Trust Royal Devon and Exeter NHS Foundation Trust Royal United Hospitals Bath NHS Foundation Tr Taunton and Somerset NHS Foundation Trust Torbay and South Devon NHS Foundation Trust University Hospitals Bristol NHS Foundation Trust Weston Area Health NHS Trust 3 0 Yeovil District Hospital NHS Foundation Trust 1 0 Grand Total Agenda Item: 10 Page 7 of 13

8 10.3 Outlier responses on Trainer Survey 10.4 National Training Survey 2016 Agenda Item: 10 Page 8 of 13

9 10.5 NTS Patient safety & undermining Qualitative Comments Severn & Peninsula 10.6 Success stories for RUH PGME in 2016 NTS CMT Radiology AIM ICU Cardiology (example below) Agenda Item: 10 Page 9 of 13

10 The RUH is developing a doctors coaching & mentoring program, led by a consultant on sabbatical for one year. Resilience is increasingly identified as an important issue in professional practice. The difficulties in achieving personal resilience are multi-factorial, but especially related to changes in working practices following EWTD which have resulted in isolation at work. A link with the Professional Support Unit at the Deanery has been developed to help to remediate problems in individuals and to look at system-wide options. The Trust has a mindfulness programme and the PGME team signpost to a variety of operations. New trainee drop in clinics during the first fortnight of August and subsequent changeovers have been developed to provide peer support. Agenda Item: 10 Page 10 of 13

11 10.7 Implementation of Junior Doctors Contract The DME and Guardian of Safe Working have a good working relationship. The RUH has developed two Educational contract models; for specialist and foundation training The potential conflict of interest arising when Educational Supervisors (ES) are asked to sign off exception reports in both working hours and education needs resolving. The Educational Supervisor is the right person to assess problems with educational delivery but should not be involved in a management issue of the working time exception reports. The views of senior educators were not sought by NHS England in reaching this decision. Senior members of the PGME team at the RUH continue to attempt to influence this decision Proposed Deanery visits The RUH should anticipate Deanery Level 2 visits (from the school and quality team) for General Surgery and Ophthalmology. In preparation, the following action plans have been developed Action Plan for General Surgery The HoD and Speciality Tutors are working to provide a pan-divisional and multi-professional weekly protected education session. The Training Programme Director (TPD) is being encouraged to improve regional teaching Agenda Item: 10 Page 11 of 13

12 The Clinical Lead is being supported to allow teaching ward rounds (already implemented for 3 days a week in some subspecialities). Continue to protect CST teaching lists. These are essential to provision of core surgical operative experience and to the ongoing allocation of CSTs to this trust. There are often threats to these lists from sudden fluxes in service pressure Action Plan for Ophthalmology There is a substantial threat to training from loss of the Emersons Green contract for cataract training. RUH s Associate DME for Quality attended a recent Quality Panel for ophthalmology, and managed to negotiate a postponement to a decision to remove 2 of our 4 trainees. There is an urgent need to protect suitable ST3-4 teaching cases at RUH. Better consultant supervision in clinics is essential. This has already improved to some extent. There is a need for better feedback to trainees in the training environment. Although there is a disparity between results of our local surveys and the NTS, our results have continued to worsen over the last four years. This, and the decision to remove trainees, has resulted in increased engagement with the consultant supervisors in the department Service Line Management in PGME The previous DME developed a model for, and started to institute, SLM for Educational Responsibility currently the Trust commits 48.5 PAs for Specialty Tutor, ES and ncs responsibility. Split funding: as SPA and as EPA currently EPA costs 253K, funded from the MADEL uplift. This is triangulated with the ES/nCS accreditation, appraisal and preparation for the JDC work scheduling. For future development of educational governance, there may be some benefit in expanding the SLM model to the rest of the budget. There was a 55% in-year reduction in the SAS educational budget for It is recommended that the Trust seeks to improve SPA allocation for other training and education doctors eg Non-Deanery funded junior doctors and new multi-professional team specialists, in order to reinforce the importance of Agenda Item: 10 Page 12 of 13

13 educational supervision in revalidation, ensuring patient safety, and to improve recruitment and retention Multi-professional working and education This is seen as a priority by both HEE and GMC. A Trust Education Group has been established to improve and expand our current multi-professional education. Junior doctor teaching is already provided together with Nurse Practitioners in the Foundation teaching programme, and in Human Factors training. However, there is considerable scope to expand this further. This may be facilitated by the Educational Levy. Successful introduction of ANPs in NICU, ENPs in ED and MNPs in medicine. Expansion of these roles is a priority to protect the trust against risks of inability to recruit to non-training grade doctor posts, and to improve flow and continuity of care, for example in haematology and clinical oncology. New Critical Care Practitioners have been recruited to ICU. Broadening and expanding the successful ESAC team 3 Advanced Orthopaedic Practitioners (physio & nurses) have been appointed to replace 1 non-training grade junior and one middle grade post, as these posts have been subject to inability to recruit safe competent calibre applicants. This will also allow the Core Surgical Trainees more appropriate service combined with improved training. A Physicians Associate has been recruited and started successfully in Stroke Medicine. There is scope to increase this through trainees from UWE, but at the moment PAs are non registered and so are unable to prescribe or order ionising radiation imaging. Risks Most NPs etc take 2 years to train so there is a cost pressure in the short term which is difficult to pass through business cases. Agenda Item: 10 Page 13 of 13

14 Compliant under Old Rota Compliant Contract/Bandin under New g Contract RAG Division Rota Name Total No of Posts Update 1 November 2016 W&C O&G ST3+ 8 1A Oct-16 David Walker Medicine F1 Acute Medicine/SAU 12 1A Dec-16 Mark Mallet Medicine F1 Medicine and Surgery 24 1B Dec-16 Mark Mallet Proposed Implementation Date Clinical lead/rota Co-ordinator Comment W&C Paediatrics F2, ST A Lynn Diskin cc Rebecca Mar-17 Winterson W&C Paediatrics ST3+ 8 1A Rebecca Winterson cc Lynn Mar-17 Diskin W&C GPST Community Paediatrics 1 No Band Mar-17 Lynn Diskin W&C GPST GUM/O&G 1 No Band Aug-17 NA Surgery ENT F2, ST A Apr-17 Stuart Gillet Surgery ENT ST3+ 2 1B Aug-17 Stuart Gillet Surgery T&O ST3+ 8 1A Aug-17 Derek Robinson Surgery Blue Rota 11 1B Aug-17 Diana Dunlop Tristan Barton, Alex Cowey, Karen Evans & trainee Selina Surgery Red Rota 8 1A Aug-17 Graham Requires 3 and 5 additional posts under new contract moving from Blue to Red Rotas (no additional posts) Surgery General Surgery ST3 7 1B Apr-17 Mike Williamson cc Julie Wiggins Surgery Urology 1 1B Oct-17 Simon Evans Surgery Ophthalmology 5 1A Jonathan Boulton/Richard Aug-17 Antcliff Medicine F2 ST1-2 Acute Medicine 14/15 1A Aug-17 Mark Mallet 1 extra person agreed August 16 to maintain level of service and ensure compliance when rota changes to 2016 contract Medicine ST3 Acute Medicine 1 1B Aug-17 Mark Mallet Medicine General Medicine F2 ST B Aug-17 Mark Mallet Medicine General Medicine ST B Aug-17 Mark Mallet Medicine ED - F2, ST A Liz Brown/Mike Price cc Nicky Aug-17 Jakeman Liz Brown/Mike Price cc Nicky Medicine ED - ST3+ 7 1A Aug-17 Jakeman Sarah Wexler cc Emma De Medicine Haematology 3 1B/1C Aug-17 Winton Sarah Wexler cc Emma De Medicine Oncology 1 1B/1C Aug-17 Winton Medicine Rheumatology 9 1B Aug-17 Ellie Korendowych Medicine GPST Ambulatory Care 1 No Band Aug-17 NA Medicine GPST Community Respiratory 1 No Band Aug-17 NA Medicine GPST Pallative Care/Pain 1 No Band Aug-17 NA Medicine GPST Pallative Care/Oncology 1 No Band Aug-17 NA Medicine GPST Elective (Dermatology) 1 No Band Aug-17 NA Medicine Neurology 1 No Band Aug-17 NA Bristol on call Medicine GPST Community Geriatrics 1 No Band Aug-17 NA Medicine Stroke Medicine 2 No Band Aug-17 NA Surgery Anaesthetics ST A Aug-17 Jenny Tuckey cc Alex Surgery Anaesthetics ST3+ 8 1A Aug-17 Jenny Tuckey cc Alex Surgery Advanced Intensive Care Med 1 1B Aug-17 Andy Georgiou cc Andy Padkin Query extra post required establishment to be reviewed prior to August 17. Surgery ITU F2 ST A Aug-17 Andy Georgiou Need 1 extra post under new contract Surgery Histopathology ST3+ 1 1B Aug-17 NA Corporate GPST GP Practice 5 No Band Aug-17 NA Surgery DCT Oral Surgery 4 1A Sep-17 Tony Ireland Additional posts/grades Compliant with new contract and signed off by clinical lead Compliant with new contract waiting final review before implementation * F2 Psychiatry Aug-17 Non compliant with new contract Radiology ST3+ (Honorary) Aug-17 Occupational Medicine ST3+ Aug-17 G U Med ST3+ (Honorary) Aug-17

15 Appendix 2 - NTS Trainer Questions