Flexible Working in Geriatric Medicine: A Workforce Statement from the British Geriatrics Society

Position paper
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Authors:
British Geriatrics Society
Date Published:
24 March 2021
Last updated: 
24 March 2021

This BGS position statement sets out the benefits of less than full time (LTFT) working in geriatric medicine for both individuals and organisations, and provides six guiding principles as well as tips for sucessful flexible working.

As an organisation, we wholeheartedly support the ambitions of the National Health Service (NHS) People Plan 2020 to embed flexible working into standard NHS practice in England.1 The NHS in Scotland has published a flexible working policy,2 as have several Health Boards in Wales, such as Hywel Dda University Health Board3 and Powys Teaching Health Board.4 According to our database of members, nearly 100 BGS members (2%) told us when they joined that they work less than full-time (LTFT). It is however important to recognise that LTFT working and flexible working are not synonymous. While LTFT working is included as one approach to flexible working, working arrangements can be flexible in other ways. This document aims to set out how LTFT and flexible working practices can be improved for the benefit of our members and the people they care for. Although this document is aimed at medical members, some themes may be relevant to colleagues from other disciplines. We support flexible working practices across the workforce delivering healthcare for older people.

In this statement we first outline the benefits for individuals and organisations of flexible working before setting out the principles of this statement. The principles are then explored in further detail and are followed by a series of hints and tips for those wishing to work flexibly and those in roles supporting flexible workers.

The right of an employee to request flexible working is enshrined in law. The Flexible Working Regulations 2014 comprise part of the Employment Rights Act 2006 and state that any employee who has worked for an employer for a continuous period of 26 weeks is entitled to make a flexible working request.5 While employers do not have to agree to a request for flexible working, they must consider such requests and if it is not possible, they must respond in writing justifying their reasons why the request has been turned down and giving clear, demonstrable operational reasons why flexible working is not possible. There is a right to appeal for employees who have a flexible working request turned down.6 Flexible working arrangements can enable those who might otherwise be disadvantaged in the workforce to access employment opportunities. These people might include (but are not limited to) staff with a disability or long-term health condition(s), staff returning to work following parental leave or adoption leave and staff with caring responsibilities.7

Flexible working enables people to have a family life and care for children and other dependents while maintaining a fulfilling career. However, flexible working is not reserved for those with caring responsibilities and employees may wish to work flexibly for a range of reasons including other career commitments such as undertaking research, special projects or professional development programmes or for personal reasons such as pursuing sport or creative activities.

Flexible working helps people to maintain a balance between their work and personal life which is beneficial to mental health. Employees then have more energy and resilience to bring to their clinical role. They are less like to suffer burn-out and are more likely to be satisfied in their work. In addition, flexible working helps to support retention of talent, something that the NHS has struggled with in the past. Between 2011 and 2018, more than 56,000 people stopped working for the NHS in England, citing lack of work life balance as the reason.1 Sometimes these people remain in roles providing healthcare but move to bank or locum work because it offers the flexibility they need.

Flexible working helps to promote diversity in the workforce, particularly by enabling new parents to combine their work and childcare commitments. While flexible working is open to everyone and both mothers and fathers may wish to work flexibly to combine work and parenting, the reality is that women are more likely to take up the option of working flexibly. Offering flexible working can help women returning from maternity leave to return to work in a way that suits them and their child/ren. As well as helping to increase gender parity in the workforce, flexible working can also help older staff members to remain working for longer. People approaching the end of their career may wish to make flexible working requests to reduce their hours or change their working pattern as they move towards retirement.7

  1. Flexible working should be normalised within the NHS. It should be available to all geriatric medicine trainees and consultants without it being viewed as abnormal or exceptional.
  2. Deaneries, NHS Trusts and Health Boards should have flexible working champions and those in senior roles should lead by example.
  3. Staff applying for or returning to work from a period of leave should be supported by their employers to make transitions as straightforward as possible.
  4. Opportunities for training, professional development, research or management roles should be adapted to ensure that those working flexibly are not disadvantaged.
  5. Organisations providing educational opportunities (such as conferences) should consider involving flexible workers in their planning.
  6. Discriminatory language and attitudes towards flexible working should not be tolerated.
    1. Non-contracted-days should not be referred to as ‘days off’ or ‘non-working days’. An alternative term used in some NHS organisations is ‘flexi-time’ which is acceptable as long as everyone involved understands what is meant by it.
    2. LTFT employees should not be made to feel they are ‘not pulling their weight’ compared to full-time working colleagues, and not be asked to fit a full-time workload into a LTFT schedule.

The UK falls behind many other countries in percentages of individuals working flexibly. In Sweden, 71% of companies offer ‘flexi-time’ working, compared to just over 50% in the UK.8 Flexible working means different things to different people and can relate to when, where and how we work. It should be up to the individual whether to disclose the reason for working flexibly. Flexible working is not reserved for those with parental responsibilities; it should be available to all. Flexible working takes many forms, including working LTFT, compressed hours, working in different locations or delivering work in different ways. The COVID-19 pandemic has seen significant shifts in the way the NHS approaches flexible working and we encourage employers to normalise these practices (Box 1).

Workforce planning should acknowledge LTFT training and flexible working. Training numbers should be increased to provide an adequate number of full-time equivalent posts. An individual working LTFT should not be expected to do the work of a full-time colleague. One way to manage this is to encourage job sharing, as this ensures a service is adequately resourced and counters the guilt an individual may feel about working LTFT. Individuals working LTFT may feel guilty about their working pattern, particularly if they are made to feel they are not pulling their weight or their working arrangement means they sometimes have to say no to colleagues or managers. Whatever approach is used, an individualised approach to job planning is required.
 

Box 1. Examples of flexible working during the COVID-19 pandemic
  • Allowing time for supporting professional activities (SPA) and continuing professional development (CPD) undertaken at home rather than in a clinical setting.
  • Shielding staff delivering scheduled care or clinics from home on virtual platforms such as Attend Anywhere or Near Me.
  • Changing hours to be flexible in the delivery of scheduled care such as evening or weekend working for clinics.
  • Reducing weekday shifts in length or number to provide extra weekend cover.

Information about flexible working options should be available in all deaneries, NHS Trusts and Health Boards. Flexible Working Champions were introduced as part of the 2018 Junior Doctor Contract Review9 and are employed by Trusts in England to help change the culture on flexible working within the NHS. This role is designed to improve rather than replace existing support for those working flexibly.

They:

  • Should be present in every deanery, NHS Trust and Health Board
  • Should have an overview of all LTFT trainees within their Trust
  • Can advise and assist any trainee on any concerns they have over the LTFT process and experience, regardless of grade and specialty
  • Can advise and support consultants working flexibly
  • Are a good point of contact for supervisors who are not familiar with supporting a LTFT trainee.

We support the role of Flexible Working Champions and encourage our members to liaise with their local support network.

As a trainee you can take time out for many reasons. Some give you the opportunity to plan ahead of time, such as research, parental leave, career breaks, additional training or working abroad. Others occur unexpectedly, such as sickness, bereavement, carer’s leave or suspension. There are clear processes for trainees on how to apply for time out of training in each of the four nations, which are easily accessible online.10-13 For Consultants the decision to work flexibly may come at the point of accepting a post, or at any point in their career. This will be subject to annual job planning meetings.

Returning to work after a period out of work can be a difficult time. People feel a mixture of emotions about the transition back to work. There is support available for trainees, both during the period that they are not working and during the transition back to work.14,15 For consultants seeking support, we would encourage contacting a Flexible Working Champion.

Many people may wish to change their hours when they return to work after a period of absence. Those employed on the NHS Scheme have the right to return to the same job under their original contract. Those planning to reduce their hours may need to renegotiate their job plan and consider the impact this will have on on-call availability. NHS employers have a duty to try to facilitate this for junior doctors in England, as supported by the NHS People Plan. The BMA outlines entitlements for employees who are planning to return to work and for working parents.16

Training programme directors (TPDs) and educational supervisors (ESs) should ensure that doctors undertaking LTFT training are adequately supported. They must be familiar with common issues that can arise for these trainees including rota management, access to educational opportunities and workplace attitudes. Guidance has been published by NHS Employers and the GMC to enable TPDs and ESs to support their LTFT workforce.17-18 Additional guidance is provided in The Gold Guide which builds on the principles of this legislation in relation to training programmes.19

LTFT trainees should be able to access the full range of training opportunities to meet all areas of the curriculum. We suggest that trainees and their supervisors develop a job plan that reflects the full-time equivalent to enable all training needs to be met (Box 2). Flexibly working trainees and consultants should not be disadvantaged in applying for management, leadership, research or educational posts.
 

Box 2. Example of a trainee job plan, working LTFT at 60%

 

Monday

Tuesday

Wednesday

Thursday

Friday

Morning

Non-contracted day

Non-contracted day

Consultant ward round

Registrar led ward round

Speciality training session

Afternoon

Non-contracted day

Non-contracted day

Clinic

SPA/admin

Ward work/Clinic

(A pro rata breakdown of training requirements is available in Annex A.)
 

There should be strategies employed to ensure LTFT trainees can access the same training opportunities as their full-time counterparts, without impacting their non-contracted days. This, for example, may mean more flexibility from the Trust to allow LTFT trainees to use offsite training opportunities (Box 3). It would be beneficial to trainees to have a list of all regional training opportunities with location, time and contact details to aid organisation and completion of competencies.
 

Box 3. Example of offsite training provision

A LTFT trainee works 60% on Wednesdays, Thursdays and Fridays and needs to attend a movement disorder clinic but the local clinic is on a Tuesday. It would be preferable for them to arrange to attend a clinic in a different hospital on one of their clinical days rather than be expected to attend the local one on their non-contracted day.

Many LTFT trainees and consultants work fixed days each week. This allows them to accommodate and plan other fixed arrangements around regular working days (such as childcare). Teaching, training days and departmental meetings are also often on set days. This puts people who do not usually work on those days at a disadvantage as they cannot attend. As attendance at these sessions is required for the annual review of competency progression (ARCP) and appraisal process, some people will give up their non-contracted day in order to attend.

In theory, trainees can claim this time back in lieu, but in reality, they rarely do. This may be due to other commitments, on call requirements, or the guilt of taking more time off. Giving up a non-contracted day also relies on flexibility in commitments outside of work which may be a challenge, especially if people rely on paid childcare.

We encourage training programmes and departments to plan the way they deliver meetings and teaching to accommodate the needs of flexibly working colleagues. The COVID-19 pandemic has made virtual learning commonplace and we encourage these practices in the long term. We encourage local rota coordinators to take the burden from the trainee and automatically re-allocate a non-contracted day if a trainee has used this time to attend mandatory training (Box 4).
 

Box 4. Example of good practice for study leave allocation

A LTFT trainee works 60% on Mondays, Tuesdays and Thursdays. All regional geriatric medicine teaching falls on Fridays. 80% attendance at teaching is required at ARCP to pass each year. The Training Programme Directors recognise this and change the teaching day each month to allow more attendance. They also ensure teaching is recorded and made available for trainees to watch at a later date.

The same trainee has to attend a mandatory Advanced Life Support course before next ARCP. The only one available locally is on a Wednesday. They arrange alternative arrangements for their caring responsibility outside of work and book the study leave. The rota coordinator acknowledges the study leave falls on a non-contracted day and automatically gives them the following Thursday off in lieu.

A similar problem exists with attending external courses and conferences. Many national conferences are held on the same days each time (Wednesday to Friday in the case of the BGS Spring and Autumn meetings). This means that people who do not normally work on these days are consistently unable to attend. The BGS is aware of these issues and in recent years has introduced live-streaming of conferences and a family room for delegates who may wish to bring children with them. The BGS has delivered all educational events online during the COVID-19 pandemic, and made session content available for 12 months after the event, so that delegates can view at a time of their own convenience. However, online events should not mask the difficulties that LTFT workers face. Online events should be considered a working day and staff who attend these events should be granted study leave and given time back in lieu if they occur on their non-contracted days. As the BGS strives to do, we encourage other event organisers to consider the needs of flexible workers.

The BGS LTFT survey conducted in 2019 showed that more than half of trainees (53%) had experienced negative attitudes towards LTFT working, some of which can be considered discrimination (Box 5).20 A culture shift to normalise LTFT working must include a change in the language used.
 

Box 5. Examples of discrimination towards LTFT workers

‘When I announced my pregnancy, a male consultant said something to the effect of ‘female doctors only get pregnant so they can work less.’

‘A consultant who emailed the other consultants in the department after SpR Ward allocations were sent out to say that she didn’t want me to be on her ward because I was LTFT and they needed a full-time SpR.’

Negative attitudes to LTFT and flexible working may often be under the radar, as opposed to outright discrimination, but they are widespread. Comments such as ‘enjoy your day off’, or ‘it seems like you are never here – what days do you work again?’ lead the individual to feel as if they are not pulling their weight and are not considered as part of the team. Comments around attendance at training events due to fixed day working, such as ‘can’t you just swap your caring day’ are unhelpful and perpetuate negative attitudes.

The language we use to describe non-working days is important. Language needs to be easy to understand but not encourage people to think negatively of people who work LTFT. People who work LTFT may use phrases like ‘off-days’ as they are easy to understand but they should not be considered as days off. Even the concept of a ‘non-working day’ does not do justice to the variety of activities that people undertake when they are not in their primary place of work. There is no one phrase that should be used to describe time when LTFT staff are not working in their medical role. We suggest that for official purposes the term ‘non-contracted days’ should be used but that for all other purposes, staff should use a term that adequately describes their use of the time, e.g., parenting day, caring day, writing day, sporting day, etc. Terms such as ‘flexi-time’ are also widely used by some organisations – we consider this to be appropriate, as long as everyone involved understands what is meant by this term.

Tips for Trusts and Human Resources
  • Ensure that your workforce planning takes into account the desire for and availability of LTFT working.
  • Ensure that you have a LTFT Champion and that this person has the information they need to support LTFT colleagues.
  • Use neutral terms such as ‘non-contracted day’ when referring to LTFT working. Other terms such as ‘flexi-time’ may be used as an alternative. Terms such as ‘day off’ or ‘non-working day’ should not be used as they diminish the importance of the activities that the individual is undertaking on those days, which may be other forms of work. Encourage LTFT individuals to use a term they are comfortable with for other purposes.
  • Ensure LTFT individuals are able and encouraged to take time off in lieu when they work or attend training activities on their non-contracted days.
  • LTFT rostering should be in line with the ‘Good Rota Design and Rostering Recommendations for LTFT Doctors’ section of the Good Rostering Guide.21
Tips for LTFT individuals
  • Make yourself aware of the support available to you, both internally and from other sources.
  • Challenge discrimination and negative attitudes to LTFT when you come across them.
  • Protect your non-contracted days as much as possible to encourage other individuals and institutions to change their attitudes.
Tips for TPDs and Educational Supervisors
  • Ensure that training opportunities are available to LTFT trainees in ways that are appropriate to their working arrangements.
  • Familiarise yourself with the common issues faced by LTFT trainees and ways to combat them.
  • Make use of the guidance available to you
  • Remember that competencies and assessments should be accrued on a pro rata basis
Tips for full-time colleagues
  • Respect your LTFT colleagues’ commitments away from your mutual place of employment.
  • Use terms that your LTFT colleagues ask you to use – do not refer to their non-contracted days as ‘days off’.
  • Support your LTFT colleagues to be part of the team.

As LTFT and flexible working becomes normalised in the NHS, as supported by the NHS People Plan, it is important that this is embraced across the system. LTFT trainees and consultants need to be supported to undertake their training and work within their designated hours. We hope that this document will help LTFT staff to understand the support available to enable them to undertake their work with confidence. We also hope that TPDs, educational supervisors, commissioners and full-time colleagues will find this document useful in helping them to understand how they can help those working flexibly.

Contributors
  • Dr Aideen Cronin, Consultant Geriatrician, Aintree University Hospital
  • Dr Claire Copeland, Consultant Geriatrician, Forth Valley Royal Hospital
  • Dr Alice Jundi, ST6 Trainee in Geriatric Medicine, Leeds Teaching Hospitals NHS Trust
  • Dr Nicola Lochrie, Specialist Registrar in Geriatric Medicine, Guy’s and St Thomas’ NHS Foundation Trust
  • Dr Lauren McCluskey, ST7 Trainee in Geriatric Medicine, Queen Elizabeth Hospital
  • Dr Zoë Monnier-Hovell, Specialist Registrar in Geriatric Medicine, Addenbrooke’s Hospital
  • Dr Gabriella Noblet, ST7 Trainee in Geriatric Medicine, Aintree University Hospital
  • Dr Susan Shenkin, Consultant Geriatrician, Edinburgh Royal Infirmary
  • Dr Kiri West, ST7 Trainee in Geriatric Medicine, Aintree University Hospital
  • Sally Greenbrook, BGS Policy Manager
References
  1. NHS England, 2020. We Are The NHS: People Plan 2020/21 – action for us all. Available at: https://www.england.nhs.uk/wp-content/uploads/2020/07/We_Are_The_NHS_Action_For_All_Of_Us_FINAL_24_08_20.pdf (accessed 26 January 2021)
  2. NHS Scotland and the Scottish Government, 2015. Supporting the Work-Life Balance PIN Policy. Available at https://www.staffgovernance.scot.nhs.uk/media/1410/supporting-the-work-life-balance-pin-policy.pdf. (accessed 26 January 2021)
  3. Hywel Dda University Health Board, 2018. Work/Life Balance Flexible Working Policy. Available at https://hduhb.nhs.wales/about-us/governance-arrangements/policies-and-written-control-documents/policies1/work-life-balance-flexible-working-policy/ (accessed 26 January 2021)
  4. Powys Teaching Health Board, 2007. Flexible Working Policy and Procedure. Available at: http://www.wales.nhs.uk/sitesplus/documents/899/Microsoft%20Word%20-%20HR036%20-%20Flexible%20Working%20Policy%20and%20Procedure.pdf (accessed 26 January 2021)
  5. UK Government, 2014. The Flexible Working Regulations 2014. Available at: https://www.legislation.gov.uk/uksi/2014/1398/made (accessed 29 January 2021)
  6. The NHS Staff Council, 2019. NHS Terms and Conditions of Service Handbook (Section 33: Balancing work and personal life). Available at: https://www.nhsemployers.org/employershandbook/tchandbook/afc_tc_of_serv... (accessed 29 January 2021)
  7. NHS Employers, 2020. What are retirement flexibilities? Available at: https://www.nhsemployers.org/pay-pensions-and-reward/pensions/pension-sc... (accessed 29 January 2021)
  8. CIPD, 2019. Flexible working in the UK. Available at: https://www.cipd.co.uk/Images/flexible-working_tcm18-58746.pdf. (accessed 26 January 2021)
  9. NHS Employers, 2020. New guidance for the champion of flexible training role. Available at: https://www.nhsemployers.org/news/2020/01/new-guidance-for-the-champion-... (accessed 29 January 2021)
  10. Health Education England, undated. Flexibility in the Medical Training Pathway. Available at: https://www.hee.nhs.uk/our-work/doctors-training/flexibility-medical-training-pathway (accessed 26 January 2021)
  11. Scotland Deanery, 2021. Out of programme (OOP). Available at: https://www.scotlanddeanery.nhs.scot/trainee-information/out-of-programme-oop/ (accessed 26 January 2021)
  12. Health Education and Improvement Wales, 2018. Out of Programme. Available at: https://www.walesdeanery.org/specialty-training/out-programme (accessed 26 January 2021)
  13. Northern Ireland Medical and Dental Training Agency, 2020. Out of Programme Policy. Available at: https://www.nimdta.gov.uk/download/out-of-programme-policy-including-application/ (accessed 26 January 2021)
  14. Health Education England, undated. Supported return to training. Available at: https://www.hee.nhs.uk/our-work/supporting-doctors-returning-training-after-time-out (accessed 26 January 2021)
  15. Scotland Deanery, 2017. Return to Clinical Practice. Available at: https://www.scotlanddeanery.nhs.scot/media/80221/return-to-clinical-practice-07-dec-17.pdf (accessed 26 January 2021)
  16. BMA, 2020. Returning to work and your rights as a working parent. Available at: https://www.bma.org.uk/pay-and-contracts/maternity-paternity-and-adoption/return-to-work/returning-to-work-and-your-rights-as-a-working-parent (accessed 26 January 2021)
  17. NHS Employers, 2005. Doctors in flexible training: Principles underpinning the new arrangements for flexible training. Available at: https://www.nhsemployers.org/-/media/Employers/Documents/Pay-and-reward/doctorstraining_flexible_principles_cd_080405.pdf (accessed 26 January 2021)
  18. General Medical Council, 2017. GMC Position Statement: Conditions for less than full-time training. Available at: https://www.gmc-uk.org/-/media/documents/less-than-full-time-training-position-statement-nov-17_pdf-72374278.pdf (accessed 26 January 2021)
  19. Conference of Postgraduate Medical Deans of the United Kingdom, 2020. The Gold Guide 8th Edition: A Reference Guide for Postgraduate Foundation and Specialty Training in the UK. Available at: https://www.copmed.org.uk/images/docs/gold_guide_8th_edition/Gold_Guide_8th_Edition_March_2020.pdf (accessed 26 January 2021)
  20. West, K and McCluskey, L, 2019, ‘Geriatric trainee experiences of less than full time (LTFT) working’, BGS Newsletter, Issue 71, 10-11
  21. BMA and NHS Employers, 2018. Good Rostering Guide. Available at: https://www.bma.org.uk/media/1979/bma-nhse-good-rostering-guidance-may20... (accessed 29 January 2021)
Annex A
Pro-rata breakdown of training and requirements for the Geriatric Medicine Curriculum

% LTFT

12-month equivalent

Duration of training year

Pro-rata number of assessments in 12-month period

Other (e.g. Audit, MSF, Patient Survey as per ARCP decision aid)

Educational Supervisor’s report

Mini-Cex

CBD

ACAT

MCR

50%

6 months

24 months

3

3

0-1

2-3

1 per training year

1 to cover each training period since the last ARCP (usually chronological 12 months)

60%

7 months + 1 week

20 months

3-4

3-4

0-1

2-4

1 per training year

1 to cover each training period since the last ARCP

70%

8 months + 2 weeks

17 months

4

4

0-1

3-4

1 per training year

1 to cover each training period since the last ARCP

80%

9 months + 2 weeks

15 months

5

5

0-1

4-5

1 per training year

1 to cover each training period since the last ARCP

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