Health & Safety
Associate Medical Director's Directorate Manager/Head of Human Resources
Medical Workforce Group/Local Negotiating Committee
01 June 2011
01 October 2014
01 September 2017

1.      FUNCTION

The requirements for monitoring trainee doctors hours of work are laid down in the contract and implementation guidance MEL(1999)40, HDL(2000)17 (and associated corrigendum), HDL(2002)33, HDL(2001)76, CEL(2008)17, HDL(2003)10, PCS(DD)2001/3 (and associated corrigendum), HDL(2005)21, Terms and Conditions of Service PCS(DD)2007/10 and model contract PCS(DD)2007/7.  NHS Fife recognises its obligation to comply with the contractual position and associated guidance.  These documents, in conjunction with the attached Procedure, outlines an agreed working practice agreed by NHS Fife and the Fife Local Negotiating Committee, with the aim of improving the local monitoring process, to ensure it is accurate and transparent and commands the confidence of key parties at all levels.       

 2.      LOCATION

This policy applies to all trainee doctors working within NHS Fife and other medical staff who work on a rota which requires to be monitored, in line with the documents detailed above.


3.1    NHS Fife


  • It is a contractual obligation of NHS Fife as the employer to ensure that all rotas are monitored to demonstrate compliance with the New Deal and the European Working Time Directive (EWTD), and on trainee doctors to cooperate with those monitoring arrangements.


3.2       Trainee Doctors


  • All trainee doctors are required to work and rest in accordance with their contracted working hours and rota template/templates.


  • All trainee doctors are required to read and comply with NHS Fife’s Procedure on the Monitoring of Trainee Doctors Hours.


  • The responsibilities of trainee doctors working within NHS Fife are as outlined under this policy and are as set out within the related Procedure document.

3.3    Acute Services Division


  • The responsibility of Rota Masters, the Medical Education Quality Manager, Medical Director, Directorate General Managers, Clinical Directors, Clinical Leads and Human Resources are also detailed within the related Procedure document

3.4    Mental Health Services


  • The Project Manager for Clinical Governance within the Mental Health Quality Improvement manages the out of hours rota for trainee medical staff and their full responsibilities, along with those of others within the Mental Health Service, are detailed under Section 3 of the related Procedure document.

4.1    Each monitoring exercise will be carried out for a minimum period of two weeks.

4.2    Routine monitoring will take place a minimum of twice a year, and more frequently where problems with compliance are identified, or where the minimum return rate is not achieved as outlined in the guidance detailed above.

4.3    As outlined in the national contract implementation guidance, a twelve-monthly monitoring agreement can be considered in cases where all parties, including the Workforce Advisor to the Scottish Government agree:

  • The posts have clearly and consistently been shown to be compliant with the New Deal.
  • The pay band for the posts are clear.
  • The pay banding is unlikely to change within the next twelve months.

4.4    Monitoring must also be carried out within six weeks of a provisional re-banding application being approved, to confirm that the appropriate banding has been applied.

4.5    Non-typical periods will be avoided e.g. trainee doctors’ change over, public holidays and examination periods.

4.6    Re-monitoring can be requested by either party and must be undertaken within a reasonable period of time.  This may arise where, for example, an individual doctor can produce well founded reasons why their hours of work, or work intensity are not adequately reflected in the results of the monitoring, or where the results vary substantially from the anticipated outcome, or following a major organisational change, or in cases of contractual dispute.  Re-monitoring will take place with the same set of doctors, wherever possible.

Before submitting a request for re-monitoring of their rota, trainee doctors who are concerned about rota compliance should inform their Rota Master of any issues.  They should allow the department time to make any changes in order to resolve the issues.  Trainees should continue to alert the Rota Master of concerns. 

If the concerns are not resolved within a reasonable period, then trainees may ask for re-monitoring of the rota.  This request should be submitted in writing at least 6 weeks before the end of the rotation in order to allow the Medical Education Department or Mental Health Service sufficient time to carry out the monitoring and to process the results.  The request must be submitted in writing, outlining the reasons for the request, and must be signed by the majority of the doctors on the rota. 

Re-monitoring of rotas should be viewed as a last resort when other attempts to resolve problems are exhausted.

5.1    Rota non-compliance resulting in increased banding payments to trainee doctors

5.2    Non recruitment / retention of trainee doctors.

5.3    Potential for removal of training status.

5.4    Reputation of NHS Fife.

5.5    Impact on General Medical Council survey outcomes.

5.6    The above risks will be mitigated by the Medical Workforce Group, which includes the Rota Masters and the Workforce Advisor for the Scottish Government.  The Medical Workforce Group will also provide a forum for sharing information on the status of rotas and any problems within the rotas, as well as forming a strategic group to co-ordinate the overall reductions in trainee numbers.  This group meets every quarter.  Mental Health Services is also represented on this group.

5.7    Regular reports will be provided by the Associate Medical Director and Human Resources to NHS Fife’s Senior Management Team, the Local Negotiating Committee, Risk Management Group and Staff Governance Committee, as appropriate

6.1    NHS Fife Procedure on the Monitoring of Trainee Doctors’ Hours

6.2    “Contacting Trainee Doctors” Procedure

6.3    Trainee Doctors Banding Appeals Policy


7.1    MEL(1999)40

7.2    HDL2000/17 (and associated corrigendum) 

7.3    HDL2002/33

7.4    HDL2001/76

7.5    CEL 17(2008)

7.6    HDL2003/10

7.7    PCS(DD)2001/3, HDL2005/21

7.8    Hospital Medical and Dental Staff and Doctors and Dentists in Public Health Medicine and the Community Health Services Terms and Conditions of Service

7.9    PCS(DD)2001/3 (and associated corrigendum)

7.10  HDL2004/34

7.11  Model contract PCS(DD)2007/7

 7.12  GMC – The Trainee Doctor – February 2011