NLG(17)206 DATE OF MEETING 30 th May 2017 REPORT FOR Trust Board of Directors Public REPORT FROM Bryony Simpson Guardian of Safe Working Hours CONTACT OFFICER Jane Heaton SUBJECT Quarterly & Annual Reports BACKGROUND DOCUMENT (IF ANY) Quarterly Reports 1 & 2, & Annual Guardian of Safe Working hours PURPOSE OF THE PAPER: For Assurance EXECUTIVE SUMMARY (PLEASE INCLUDE A BRIEF SUMMARY OF THE PAPER, KEY POINTS & ANY RISK ISSUES AND MITIGATING ACTIONS WHERE APPROPRIATE) The Quarterly report Jan- April 2017 details the update on the Exception reporting system which is a part of the 2016 contract TCS for Junior doctors. It examines issues arising from the process and possible solutions. This is the first Annual report of the Guardian of Safe Working Hours summarizing the issues regarding medical staffing and the resulting effects on trainees. HAVE STAFF SIDE BEEN CONSULTED ON THE PROPOSALS? NOT APPLICABLE HAVE THE RELEVANT SERVICE USERS/CARERS BEEN CONSULTED ON THE PROPOSALS? NOT APPLICABLE
ARE THERE ANY FINANCIAL CONSEQUENCES ARISING FROM THE RECOMMENDATIONS? YES IF YES, HAVE THESE BEEN AGREED WITH THE RELEVANT BUDGET HOLDER AND DIRECTOR OF FINANCE, AND HAVE ANY FUNDING ISSUES BEEN RESOLVED? YES ARE THERE ANY LEGAL IMPLICATIONS ARISING FROM THIS PAPER THAT THE BOARD NEED TO BE MADE AWARE OF? YES WHERE RELEVANT, HAS PROPER CONSIDERATION BEEN GIVEN TO THE NHS CONSTITUTION IN ANY DECISIONS OR ACTIONS PROPOSED? YES WHERE RELEVANT, HAS PROPER CONSIDERATION BEEN GIVEN TO SUSTAINABILITY IMPLICATIONS (QUALITY & FINANCIAL) & CLIMATE CHANGE? YES THE PROPOSALS OR ARRANGEMNTS OUTLINED IN THIS PAPER SUPPORT THE ACHIEVEMENT OF THE TRUST OBJECTIVE(S) The 2016 contract is mandatory THE PROPOSAL OR ARRANGEMENTS OUTLINED IN THIS PAPER ENSURE COMPLIANCE WITH THE REGULATORY OR GOVERNANCE REQUIREMENTS LISTED 2016 TCS THE PROPOSALS OR ARRAGEMENTS OUTLINED IN THIS PAPER TAKE ACCOUNT OF REQUIREMENTS IN RESPECT OF EQUALITY & DIVERSITY YES ACTION REQUIRED BY THE BOARD The Board is asked to note the update regarding the implementation of the 2016 contract and the obstacles encountered together with recommendations for future action.
Board of Directors Guardian of Safe Working Report Q4 report Jan- April 2017 1. Introduction and background This is the second quarterly report concerning the progress of the Guardian of safe working hours, Exception Reporting system for the quarter January to April 2017. The system is that established by the 2016 Terms and Conditions for Junior Doctors and Dentists. There are no Trainees within the Dentistry service at NLG and so the report applies only to Junior Doctors. The 2016 national contract for junior doctors encourages stronger safeguards to prevent doctors working excessive hours. The Guardian role was introduced with the responsibility of ensuring doctors are properly paid for all their work and by making sure doctors aren t working unsafe hours. The role sits independently from the management structure, with a primary aim to represent and resolve issues related to working hours for the junior doctors. The work of the guardian will be subject to external scrutiny of doctors working hours by the Care Quality Commission (CQC) and by the continued scrutiny of the quality of training by Health Education England (HEE). These measures should ensure the safety of doctors and therefore of patients. The Guardian will: Champion safe working hours. Oversee safety related exception reports and monitor compliance. Escalate issues for action where not addressed locally. Require work schedule reviews to be undertaken where necessary Intervene to mitigate safety risks. Intervene where issues are not being resolved satisfactorily. Distribute monies received resulting from fines for safety breaches. Give assurance to the board that doctors are rostered and working safe hours.
Identify to the board any areas where there are current difficulties maintaining safe working hours. Outline to the board any plans already in place to address these Highlight to the board any areas of persistent concern which may require a wider, system solution. The Board will receive a quarterly report from the Guardian, which will include: Aggregated data on exception reports, broken down by categories such as specialty, department and grade. Details of fines levied against departments with safety issues. Data on rota gaps / staff vacancies/locum usage A qualitative narrative highlighting areas of good practice and / or persistent concern. Work scheduling junior doctors and employers will be required to complete work schedules for the doctors in training. This will begin as a generic schedule setting out the hours of work, the working pattern, the service commitments and the training opportunities available during the post or placement. Juniors also need a personalised work plan, devised with their Educational Supervisor, to ensure that they meet their training and development requirements and are able to update their Portfolios for their ARCP reviews. The duty roster should be provided at least six weeks in advance of the doctor starting in post. Exception reporting enabling doctors to raise exception reports where their work schedules do not reflect their work, and to ensure that a work schedule remains fit for purpose. This is beneficial to employers as it will give real-time information and identify key issues as they arise. It also benefits doctors, as issues over safe working or missed educational opportunities can be raised and addressed early on in a placement, resulting in safer working and a better educational experience. 2. Guardian of Safe Working Report Implementing the Role The Guardian has now been in post since December 2016 and liaises at a national and regional level with other Guardians. to The Guardian has been working closely with the Director of Medical Education and colleagues from medical staffing, rostering, post graduate medical education, human resources and finance to establish the role in the Trust and build relationships. For some aspects of the system guidance is still being written by NHS Employers and all employers are learning together as the system is rolled out. In December 39 FY1 junior doctors in the Trust transferred onto the contract. By the end of 2017 all junior doctors will be
on the new contract. The table below shows the number of trainee posts available and filled by Health Education Yorkshire and the Humber. Some of the vacancies have been filled by the Trust. SGH DPOW Grade Posts Filled by trainees Posts Filled by trainees F1 24 21 24 18 F2 22 22 25 21 GPVTS 10 7 12 6 CT 1/2 20 8.5 20 13.09 ST 1/2 38.5 30.7 38 11.78 TRUSTGRADES Posts Filled Posts Filled Challenges Engagement Engagement with the Junior Doctors has largely taken the form of the regular meetings of the Safe Working Hours - Junior Doctors Forum (SWHJDF). The Guardian is supported by the two BMA, Junior Doctor representatives from DPOW and SGH who liaise with their peers informing and encouraging them. An information and training package has been devised for delivery by the Guardian at Induction sessions. The Junior Doctor representatives regularly liaise with the Guardian regarding any ongoing issues. The BMA regional representative attends the SWH JDF. The LNC Chair or deputy has a place at the SWH JDF and receives the minutes of meetings and copies of Board reports. Engagement with the Educational Supervisors (ES) and other Consultants has been challenging. The Contract specifies that Educational Supervisors should respond in a timely fashion, within 14 days of the Exception report being logged. They should agree/disagree with the report and decide on action- either TOIL or payment. Training regarding the system and Q and A sessions have been delivered at MAC, HCC, Educational Supervisors meeting, sub regional Education meeting, the Dean s Conference, the area Education Committee and on a 1-1 basis by request. All Consultants have been given details of an e-learning package, which takes 15-20 minutes to complete and is available to all. Some ES do not agree that they have a role in this, despite it being a Contractual requirement and discussions are underway to resolve the issue internally.
Software System The Trust uses a nationally procured system for medical staff rotas called the Doctors Rostering System 4, which is the system now used for exception reporting. Each junior doctor on the new contract has been given log in details and been registered on the system to submit an exception report as necessary. The Educational Supervisors have also been registered and set up on the system. This process must happen with each rotation. The Guardian has sight of all reports and responses. The DRS4 does not speak to payroll and thus all requests for additional payment for hours worked must be administered manually. Therefore the Guardian has written a local protocol for the smooth transfer of information from DRS Medical Staffing to Finance and payroll to ensure that JDs are paid any monies owing on time. We are working closely with the authors of the system, Skills for Health, and making improvements incrementally. The Guardian has written a protocol for the smooth payment of extra hours incurred via Exception Reporting. This internal process to record and validate payments in line with the current payroll cut off period for prompt payment of additional hours is now up and running. Workload NLaG have allotted four hours per week to the Guardian Role to cover NLG and Navigo. In the long-term this may be adequate but during the introductory phase there has been much extra work. The Guardian is also taking on the trainees hosted by Navigo from 1 st September and although small in number they will require Induction training and regular liaison. To date, within NL&G it is only the FY1s who are on the new system but the system encompasses all others on the 2016 contract from September Currently the Guardian has been assisted by admin from Post Graduate Education. The Medical Staffing Manager, Caroline Taylor has also been hugely supportive in introducing the new system, answering queries from users and devising and introducing an escalation process to aid the educational supervisors with the timescales for responding/authorising ER s. The new contract does have workload implications for both educational supervisors and clinical supervisors when a trainee submits an exception report. The amount of time will depend on the number of exception reports submitted and it is too early to make a judgement about this currently. Junior Doctors Forum The Guardian has established the Safe Working Hours- Junior Doctor Forum (SWHJDF); there is one forum across both hospital sites. This has now met 4 times. The first two meetings were arranged after work from 5-7 pm but this was changed at the Junior s request to be held within working hours, from 12-2pm. Attendance has varied and many struggle to make time to leave their front line, job roles. The Contract Guidance calls for quarterly SWH JDFs but at the request of the Junior Doctors in NL&G it was agreed to meet more frequently in the first 6 months until the system was well established. Terms of reference and membership have been agreed. Every effort has been made to widen the junior doctor membership of the Forum to encourage a more diverse representation across the Trust. The following issues have been discussed at the Junior Doctor Forum: Inadequate IT provision at SGH means JDs are queuing to load information Rotas in Surgery need reviewing because of ongoing vacancies Short notice of changes, sometimes on the day, mean that Juniors are unable to plan life outside of work and do
not know from day to day where they will be working A chain of escalation is not always in place this includes juniors working on RDaSH site but employed by NLG Lack of back up in Surgery overnight Handovers planned regularly outside of the Junior s working hours Ward rounds late in the day meaning all JD jobs arising from the ward round detain the JD after their allotted time. Lack of staff- particularly senior cover Inappropriate tasks being assigned to JDs An Action log of tasks arising from the SWH JDF is maintained and monitored by the Guardian. Exception Reports and Fines. The whole point of the exception reporting system is to allow employers to address issues and concerns as they arise, in real time, and to keep doctors working hours, both rostered and actual, within safe working limits. If the system of work scheduling and exception reporting is working correctly then most reports should be responded to with TOIL as the spirit of the agreement is that JDs hours are not excessive during the course of a week and extra payments and fines kept to a minimum. Any levying of a fine should therefore be followed by an investigation in to why it was necessary and remedial action to ensure that it does not happen again. The most important thing to remember is that fines should rarely, be applied at all. To the end of March 2017 one fine has been imposed by the Guardian for exceeding a working time of 72 hours in 7 consecutive days. This was incurred in the Cardiology placement at DPOW. The fine imposed amounted to 7 hours at 31.57 = 221.02 for the 72 hours breach in 7 days, paid to the JD and 132.62 for the Guardian SWH JDF training fund. From 1 st January 2017 to 31 st March 2017 we have received 80 exception reports from 9 Doctors totalling 101.7 hours. DPOW 56 exception reported total hours 70.25 48 exception reports agreed of which 48.75 hours to be paid as additional hours 8 exception reports Yet to respond total 11.5 hours 8 hours given as TOIL 2 exception reports agreed as no action required total 2 hours Cardiology has received a guardian fine for 72 hours breach in a 7 day period SGH
24 exceptions reported total hours 31.45 8 exception reported total 10.95 hours to be paid as additional hours 16 exception reports Yet to respond total 19.5 hours 3 exception reports agreed as no action required total 1 hour There have been some early outcomes associated with these reports including; identifying some individuals/areas who need to be better supported and others which have resulted in Rota redesign- Surgery. However, concerns by junior doctors have been expressed as comments are being made on the ward about why exception reports are being raised and what outcomes they are generating along with speculation about who has raised them, and this only serves to promote a blame culture and discourage junior doctors from reporting. Escalation We are struggling to engage Educational Supervisors (ES) in the process and are breaching our time targets for responding to the Exception Reports. To try and improve performance on this front we have devised an Escalation process, agreed with the SWH JDF, which involves the Medical Staffing Manager sending a reminder alert to the ES and their administrative support requesting that they action the ER and offering to support them if they are unfamiliar with the system. To date this is having little success and the Guardian has had to send individual reminders to ES and then intervene with some very overdue ERs and action them in lieu of an ES response This is unsatisfactory and against the Contract guidance. Rota Site Nature of Exception Number of reports Recommen d pay Recommen d TOIL Fines Imposed Paediatrics DPOW Education 1 n n N/A Paediatrics DPOW Rest/Exceeding contracted hours. 11 4 8 N/A Paediatrics DPOW Rest/Exceeding contracted hours/education. 1 1 n N/A Medicine DPOW Rest/Exceeding contracted hours. 38 27 1 1 Surgery DPOW Rest/Exceeding contracted hours. 3 3 n N/A General Practice DPOW Rest/Exceeding contracted hours. 1 1 n N/A
Medicine SGH Rest/Exceeding contracted hours. 1 1 n N/A Surgery SGH Rest/Exceeding contracted hours/education. 23 1 n N/A Total 79 33 9 1 Added the above Rota Gaps for Doctors Currently on New Contract Jan March 2017 SGH Vacancies During this quarter there was an average vacancy rate of 4.47 wte average Junior Doctor Vacancies at SGH. DPOW Vacancies There was an average vacancy rate of 8.41wte Junior Doctor Vacancies at DPOW. Locums
December 2016 Agency figures Total hours Total shifts sent to agency Agency filled Internal bank 16821 1864 507 208 37 January 2017 Agency figures Total hours Total shifts sent to agency Agency filled Internal bank 21365 2330 642 224 61 Grade booked January Shifts Consultant 64 CT 85 F1 29 F2 61 GPVTS 13 Middle grade 5 Reg 18 SHO 140 SpR 142 Spec. Dr 87 St2 1 Str (St3 +) 20 St 1-2 1 Trust grade (junior) 4 February 2017 Agency figures Total hours Total shifts sent to agency Agency filled Internal bank 18651 2057 710 158 171 February Grade booked Shifts Consultant 56
Ass. Spec 2 CT 76 F1 57 F2 46 GPVTS 16 Middle grade 9 Reg 18 SHO 115 SpR 87 Spec. Dr 151 St2 1 Str (St3 +) 20 St 1-2 1 Trust grade (junior) 20 St4 10 St3 4 St1 14 Trust grade (senior) 1 March 2017 Agency figures Total hours Total shifts sent to agency Agency filled Internal bank 21050 2294 860 158 313 March Grade booked Shifts Consultant 166
Ass. Spec 4 CT 109 F1 86 F2 48 GPVTS 8 Middle grade 17 Reg 3 SHO 40 SpR 95 Spec. Dr 197 St2 1 Str (St3 +) 20 St 1-2 1 Trust grade (junior) 23 St4 4 St3 12 St1 15 Core trainee/st1-2 (formally SHO) 25 Str 3-8 49 Networking The Guardian is attending national meetings and training and is a member of the regional forum of safer working guardians as well as having email contact with a number of other Guardians in the region to share updates etc. There is a view that junior doctors are reluctant to report excess hours, for fear of damaging their relationship with their training /clinical supervisor - even possibly affecting their jobs in the future, hence the culture of no blame being of utmost importance. Some Trusts have chosen to act against BMA instructions and to use Clinical Supervisors to action ERs with various levels of success. Their argument is that Clinical Supervisors are closer to the issue and they are better acquainted with the day to day service issues. This has been discussed at the NL&G SWH JDF but the Junior Doctors felt that this system could lead to difficulty in working relations with clinical supervisors and wish to retain the ES as the one who decides on the outcome of the ER. Next Steps To encourage wider junior doctor engagement in the Forum and better consistency in the information uploaded as part of the ERs, by training on the ER system, introducing the Guardian role, and the principles behind the Forum by attendance at each junior doctor induction/training events. To increase engagement and support Educational Supervisors as they familiarise themselves with the new
system and make decisions. To ensure that all Consultants are aware of their contractual duties regarding the 2016 contract TCS and are trained on the system to ensure that they respond to JDs in an appropriate and timely fashion. To continue to implement the Escalation process and speed up the responses to ERs ensuring they are dealt with within the specified time. To implement the new financial system and ensure that JDs are paid any monies owing on the next available pay day. To ensure effective communication with all relevant parties to maximise safe working and effective training. To ensure that Navigo JDs are included within the system and receive a service tailored to their requirements. 3. Conclusion The roll out of the 2016 Safe Working Hours TCS continues and the NL&G system is developing slowly. Many Juniors have embraced the system and are genuinely committed to Exception Reporting and maintaining a professional work-life balance, promoting safe working. Information gleaned from the ERs enables the DME to keep informed of the challenges and threats to the provision of quality Trainee placements at NL&G. Much work has been done to devise internal systems for Escalation and payment of hours. The challenge increases in the area of Consultant engagement and improving the response to their contractual duties. 4. Recommendation 1. The Board are asked to read and note this second, quarterly report from the Guardian of Safe Working Hours. 2. The Board are asked to support robustly the encouragement of clinical directors, directorate managers and educational supervisors to be aware of their responsibilities within the new contract.
Author Bryony Simpson Guardian of Safe Working Owner Chief Executive Date April 2017
ANNUAL REPORT ON ROTA GAPS AND VACANCIES: DOCTORS IN TRAINING Executive summary The Annual Report of the Guardian of Safe Working Hours will present the Rota gaps and vacancies from December 2016 to end of April 2017 which is the period in NL&G of operation of the 2016 contract for FY1 Junior Doctors and the period since the appointment of the Guardian. There are no Trainees within the Dentistry service at NLG and so the Annual Report applies only to Junior Doctors. The 2016 national contract for junior doctors encourages stronger safeguards to prevent doctors working excessive hours. Negotiations on the junior doctor contract led to agreement on the introduction of a 'guardian of safe working hours' in organisations that employ or host NHS trainee doctors to oversee the process of ensuring safe working hours for junior doctors. The safety of patients is a paramount concern for the NHS. Significant staff fatigue is a hazard both to patients and to the staff themselves. The safeguards around working hours of doctors and dentists in training are outlined in the terms and conditions of service (TCS) and are designed to ensure that this risk is effectively mitigated and that this mitigation is assured. Recruiting and retaining doctors is a widespread challenge in the NHS and one that requires a strong workforce strategy within each Trust to address the unique challenges of that area. There has not been a 100% fill rate for Junior Doctor posts at NL&G for many years, and there is unlikely to be in the future. This, combined with the challenges of recruiting Consultants locally, means that there needs to be a robust and sustainable plan to provide sustainable and realistic solutions to the staffing problem. These solutions, whilst including previous strategies, casting the net wider and making the area more attractive for potential doctor employees, should also include the evidence based work of HEE and other Trusts in Yorkshire and the Humber such as, the development/employment of Advanced Clinical Practitioners who have been in place in other Trusts for upwards of ten years and the employment of the newer Physician s Associates, the first local cohort graduate this year. As well as building capacity in our workforce, this includes the development of new and advanced roles and innovative attitudes toward the mix of skills in teams. Trusts locally have successfully used ACPs to replace gaps in the Junior Doctor rota. A range of solutions will reduce the dependency on Junior Doctors and decrease pressure on medical staffing whilst providing an equal or increased level of quality services to patients.
Rota design and co-ordination is vital for effective and safe staffing. The latest requirement is that Junior doctors are provided with rotas 8 weeks in advance. Performance on this within NL&G is variable and there is a pilot at DPOW studying the centralization or rota coordinators. The outcome should be that rotas are issued 8 weeks in advance across all specialties and are compliant with the TCS of the 2016 contract. Non-compliance may lead to Exception reporting by Junior staff and fines if any of the four following conditions are breached. An average 48 hour working week over the course of a rotation Exceeding 72 hours in any consecutive seven-day period Minimum 11- hour rest has been reduced to less than 8 hours Meal breaks are missed on more than 25% of occasions Introduction The Guardian of safe working hours: Ensures that issues of compliance with safe working hours are addressed by the employer/host organisation and/or doctor Provides assurance to the Board of the employing organisation that the doctors' working hours are safe. The purpose of this Annual report is to provide data regarding staffing, rota gaps and the effect that these are having on safe working hours, training and service delivery. The Report will draw some conclusions from the data and make recommendations regarding possible ways forward to resolve the issues raised indicating any Board action necessary. High level data Number of doctors / dentists in training (total): 180 Number of doctors / dentists in training on 2016 TCS (total): 38 Annual vacancy rate among this staff group: 26.31%
Annual data summary Specialty Grade Quarter 1 Quarter 2 Quarter 3 DEC Quarter 4 Jan, Feb, March Total gaps (average WTE) Number of shifts uncovered (over the year) Gastro F1 1 1 Gen Surg F1 2.5 2.5 Emergency F1 1 1 Med Cardiology F1 1 1 Orthopedics F1 1 1 20 20 Respiratory F1 1 1 Endo F1 1 1 Total 7.5 7.5 Average no. of shifts uncovered (per week) Actions taken to resolve As stated there is a vacancy rate of 26.31% which has resulted in Locum requirements which have been filled by external and internal locums. Although there are shifts uncovered in Orthopedics they have assured us that this has not had any detrimental effect on patient care. Workforce and Recruitment meetings take place regularly with Medical Staffing to identify and plan for vacancies. Vacancies are advertised and active steps taken to follow up an interest in the area. The Trust have recently employed a Talent Acquisition manager to focus on vacancies and work with recruitment agencies There have been concerns raised in Cardiology at DPOW about safe staffing, with Exception Reports being logged regularly and a fine imposed for a trainee working more than 72 hours in 7 days. Discussion has taking place with the MD and DME regarding solutions to the persistent issues and the possibility of removing trainees from this specialty at DPOW considered. Currently as there is a full rota going forward and the incoming trainee has agreed to the rotation the DME has decided to continue with a trainee in this placement. The Guardian, with the DME, will monitor quality in this are going forward and consider the need for any further changes. Exception reports from the Psychiatry rotation in Scunthorpe, hosted by Rotherham, Doncaster and South Humber Trust have given cause for concern on several fronts regarding safe staffing and the DME is currently in dialogue with RDaSH to resolve these issues going forward. The Guardian is monitoring the response to ensure safe working practices relating to FY1s employed by NLaG.
Summary and Questions for consideration Staffing levels within NLaG give cause for concern. The vacancies and rota gaps described above have led to some Junior Doctors working consistently above their hours and in one instance leading the Guardian to impose a fine. The Medical Director (MD) and Director of Medical Education (DME) have considered the withdrawal of Junior Doctors within this specialty and have agreed to the current rotation based upon the knowledge that the specialty rota is fully staffed and the current Junior doctor has agreed to the rotation. The guardian will join the MD and DME in monitoring this placement during the current rotation to ensure that safe working hours and education requirements are met. The Guardian has raised concerns that too much dependence is placed upon recruiting doctors and more needs to be done to develop alternatives such as Physician s Associates (PA) and Advanced Clinical Practitioners (ACP). Most other Trusts in Yorkshire and the Humber have been developing such roles as ACPs e.g. Hallamshire Hospital, Sheffield, runs its Hospital at night service with ACPs, York has developed 20 plus ACPs. Full financial support has been available from HEE Y&H for many years to develop these roles but NLaG has not taken up the offer of this support. Developing these roles has been shown to reduce dependence on medical staff and provide quality, sustainable care for patients. Such action would mitigate the rota gaps and help to ensure continuity of care and staffing. Concerns have been raised regarding the timing of Annual Leave for senior staff with examples of several consultants in single specialties being granted leave at the same time. This has been raised with the DME, MD and medical Staffing who are addressing the issue. There is evidence that the workload has been excessive for some Junior Doctors as evidenced by Exception reports and these specialties have been asked to address this. Cardiology at DPOW has a poor track record with Trainees. Engagement by Consultants with the new contract has been slow to emerge and attendance at meetings/training has been poor. Despite all Consultants being offered 1-1 training, there are still many that are not responding to the ERs logged by their trainees. The ERs contain much useful information regarding the working situation, patient care and staffing. The Trust can benefit from this information to improve its services and monitor working conditions and practices. Issues of Rota co-ordination, and how this is managed and delivered, need to be resolved by the Trust to ensure a reliable system that conforms with regulations whilst providing a safe level of staffing. Recommendations 1. The Trust is advised to give urgent attention to a realistic and sustainable Workforce strategy with deliverable plans to mitigate the risk within medical
staffing and develop and employ PAs and ACPs. 2. There needs to be an enforcement of the Annual Leave Policy to prohibit all the Consultants in one specialty taking leave at the same time. 3. Monitoring of the situation and quality of training in Cardiology at DPOW to ensure the provision of the HEE requirements for trainees. 4. Enforcement of the Consultant s contractual duty to respond to ERs logged by their Trainees within 14 days. 5. The Rota co-ordination pilot and its findings need to be used to inform and improve performance in this area. Bryony Simpson Guardian of Safe working hours Northern Lincolnshire and Google NHS FT.