• Junior doctors sometimes reluctant to exception report, HSJ told
  • British Medical Association warns no exception reports are a “red flag”
  • Guardian of safe working hours says culture is gradually changing

Junior doctors have learnt to live in an “unhealthy culture” with “a significant amount of Stockholm syndrome”, HSJ has been told.

Simon Fleming, orthopaedic registrar and past president of the British Orthopaedic Trainees Association, said there was a “significant amount of Stockholm syndrome” among trainees.

“We have learnt to love this unhealthy culture we work in. A lot of junior doctors don’t appreciate how powerful exception reporting is,” he said.

His comments came as HSJ analysis of data from more than 200 NHS trusts revealed there have been 63,309 exception reports from almost 36,000 trainee medics since the introduction of the controversial new junior doctors’ contract in August 2016.

Exception reporting allows a doctor to file a report when they work beyond their contracted hours or work without breaks, as well as other contract breaches.

Jeeves Wijesuriya, chair of the British Medical Association’s junior doctors committee, told HSJ he was not worried about trusts with high numbers of reports, because it suggested “a culture of wanting to make things better”.

“The places I worry about are where there are no exception reports,” Dr Wijesuriya said. “That’s a real red flag. We can see the General Medical Council and Health Education England looking at places that have no record of exception reporting.”

Among the data examined by HSJ, four NHS trusts which employ junior doctors on the new contract reported no exception reports between August 2016 and July 2018. These were Sussex Community Foundation Trust, The Robert Jones and Agnes Hunt Orthopaedic Hospital Foundation Trust, The Royal Orthopaedic Hospital Foundation Trust and The Walton Centre Foundation Trust.

Dr Wijesuriya added: ”It’s a big cultural shift and it’s relatively early days. Foundation doctors are exception reporting more than senior ones. Doctors that are used to different monitoring systems haven’t adapted to the new system.”

He continued: “Once [exception reporting] normalises, that is when we will start to see changes. It gives you your business case for additional staff – you can show in the department where the need is.”

The BMA is currently working jointly with NHS Employers and the government to review the 2016 contract, which led to a bitter dispute with the government and the first strike action by junior doctors in 40 years.

Danny Mortimer, chief executive of NHS Employers, said exception reporting was still a “relatively new process”, noting: “Although the process is working well overall, there are areas where guardians of safe working hours and doctors tell us improvement is needed.

He added: “Exception reporting is therefore being discussed as part of the junior doctor’s contract review by NHS Employers and the British Medical Association. The review has a strong focus on safety and training and ensuring that exception reporting works as intended.”

Culture “gradually changing”

Jorge Zimbron, guardian of safe working hours at Cambridgeshire and Peterborough Foundation Trust and Cambridgeshire Community Services Trust, said the culture around exception reporting was “gradually changing”.

“In large trusts the calculations that result in fines are often being made by an admin person hired by the trust so there is a lack of transparency and conflict of interest,” he said. “There is also room for human error.”

Dr Zimbron explained the national exception reporting systems are “not very good” so he created and programmed his own system, which has been “very well received”.

Although he acknowledged there is still a “reluctance to exception report”, he said reporting is being used to improve training at the trust. “We had problems with trainees staying late to take routine bloods so we used data to support a business case for a phlebotomist,” he added.

A Hospital Consultants and Specialists Association spokesman said it was “no surprise that junior doctors have reported rota breaches in their tens of thousands” and added the Department of Health and Social Care cannot be “absolved of responsibility” for the wider medical staffing crisis.

Exclusive: Tens of thousands of junior doctors working beyond contract