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

Introduction

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.

Benefits of flexible working

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

Principles

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.

1. Normalising flexible working

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.
 

2. Flexible Working Champions

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.

3. Transitions to and from a period of leave

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

4. Maximising opportunities

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.
 

(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.
 

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).
 

5. External training events

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.

6. Language and attitudes

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.
 

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.

Hints and tips

Conclusion

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.