Analysis & Synthesis of Pain points in LTFT Processes

Given the identified challenges and issues related to the LTFT (Less Than Full Time) process at discovery, it is clear that there are several pain points, including communication gaps, unclear processes, and administrative burdens. This page created by the Business Analysts provides a summary of those along with some potential suggestions or actions to consider at alpha phase in addressing these challenges in the to-be process/s and solution-designing options that fit the target operating process/s.

Pain Points in the LTFT Process

The below are the the pain points collected during discovery around the LTFT processes for each Local Office.

London

1	Trainees have difficulty understanding Deanery and HEE (NHSE) being the same entity.
2	TPD / FTPD / GP Scheme manager are not normally discussing the impacts of LTFT on their training. E.g. impact on their CCT date and pay changes when having their initial discussion
3	A significant proportion of rejections due to trainees submitting applications outside published window. (See above table.)
4	Trainees having to reapply for LTFT following rejections, where they have applied outside HET window.
5	Trainees having to reapply for LTFT where rejection was due to insufficient supporting evidence despite being chased.
6	Approval emails are automatically sent to trainees except for Childcare reason where this is sent manually.
7	There is no SLA published to trainees currently in managing their expectations, but only internal to the HEE team on processing applications timeline.
8	The only determining factors and national guidelines available are for rejections where either there were insufficient supporting evidence/s for the LTFT category applied under.
9	The HET window is a Local Office arrangement and decision to reject applications under respective categories. (See approval processes)
10	The negotiation of work pattern not taking place until an approval received from HEE(NHSE).
11	There is currently no specific ETA/SLA by Head of Schools / Deputy Deans in providing a decision for an appeal where the application was rejected.

Thames Valley

1	Revised CCT end date is asked on the form, however, there are no Local Office resources available to support the trainee apart from the Royal Colleges guidance and calculator. This has to be manually verified before inputting to TIS.
2	Once approved, does it remain for the duration of the programme or until trainee decides to make a change by submitting an application? Until end of prog. Or new request to change. Sometimes it doesn’t get fed down. Which can have implication on their pay if the % is not reflected without paperwork.
3	There is no SLA published to trainee on expectation of dates on outcomes of applications
4	Applications applied too early are rejected and trainees asked to re-apply within application window. E.g. If a child is not born yet and an application is made on the basis of childcare, they are rejected and asked to apply after child birth.
5	Calculation of CCT for GP is done by the Royal Colleges whereas in Specialty they are done by the admins team at ARCP. The reason GP moved to Royal Colleges was because of the amount of errors in calculating the data.
6	TV uses Local and National spreadsheets in order to support the processing of applications. Currently a Local and a National spreadsheet that have to be completed manually. This is an admin burden and prone-to-error practice.
7	TV has documented process with Trainee, Associate Dean and Postgraduate Dean involved in an appeal process, however, in practice no rejection insofar has reached to this stage following rejection.
8	The form is a WORD Doc and can be filled in manually or by using a Computer. It is prone to miss filling in required information. It can also be time-consuming having to print, manually fill, scan and send to NHSE TV.

East of England

1	There is usually a number of complaints received from Medical Staffing due to short notice received on applications and time to process those.
2	The current for is in Adobe PDF format and requires a few signatures to be provided electronically. Adobe compatibility makes it difficult to download and open/sign the form. The form would not load on all Adobe versions and not if opened on a browser.
3	There normally should be discussions as early as possible between Trusts, TPDs, Deans and Local Office in general on Post funding, although this is normally happening a bit late in the process therefore adding delay to approving applications.
4	Applications are approved for the whole duration of a training programme for EOE and does not require reapplication at every rotation, however, there are complaints received from Trusts about not receiving applications around August period when trainees rotates.
5	There is a manual process to support trainees in exceptional circumstances (e.g. where trainee has a disability) whereby a Word version of the form is sent to the trainees to be manually filled in, scanned and emailed back to Programme Team who then completes the PDF version on their behalf and sent for processing.
6	Supporting documentation are kept on shared folders and have sync issues sometimes rendering them inaccessible.
7	Programme team tends to receive a number of applications with missing mandatory elements including Signatures and have to be sent back, which delays the process.
8	There are very little to no validations on the form that impacts on the quality of the data received and adds delays to the processing.
9	It is quite often the case where trainees have not re-calculated their new CCT correctly or not aware that it will be impacted by LTFT and there fore submitting with their original CCT rather than an updated one.

Yorkshire & Humber

1	Given the new policy to extend flexible training, there has been a large number of applications and it has meant that the categories no longer exist. This in turn has made the triaging of applications almost ad-hoc and unmanageable when it comes to prioritising the processing as and when the applications are received based on the reasons. E.g. there is no Local process to prioritise the processing of Childcare/Disability/Health reasons applications over wellbeing ones.
2	It can take significantly more time where applications are submitted with less than 12 weeks notice to process due to approval required from Trust in Y&H process. This may require chasing the Trust who are also operating within their own constraints.
3	Y&H uses Tracker spreadsheets in order to support the processing of applications. Currently a Local and a National spreadsheet that have to be completed manually. This is an admin burden and prone-to-error practice.
4	There isn’t always an opportunity in the Y&H process for trainees to be discussing with the Trust directly regarding their ability to accommodate for LTFT for a rotation, as the trainee may not be at the specific Trust they are going to be rotating yet where they intend to train as LTFT.
5	Y&H has a extensively documented process with Trainee, Associate Dean and Postgraduate Dean involved, preparing cases statements, with timescales made aware to the parties involved. However, in practice, this has not yet happened as there have been no rejections yet.

South West Peninsula & Severn

There is no SLA to process applications neither internally nor published to trainees when an application has been submitted. Trainee doesn’t have an indication of where their application are with the processing and receiving an outcome.

Given the new policy to extend flexible training, there has been a large number of applications and it has meant that the categories no longer exist. This in turn has made the triaging of applications almost ad-hoc when it comes to prioritising the processing as and when the applications are received for specialty. E.g. there is no Local process to prioritise the processing of Childcare/Disability/Health reasons applications over wellbeing ones.

Although the numbers are less for Dental and GP in SWP.

SW uses different forms for 1) Change of percentage 2) New Application 3) Notification of Appeal. All these forms can be difficult to manage when submitted to HEE via emails. When submitted to HEE they go to personal email addresses of Specialty Education Programme managers which can be difficult to triage as to what the purpose of the email was from the trainees.

The role of Education Specialty Programme Managers in HEE is unclear in the approval process. For Caring responsibilities, currently they only rely on the TPD having ticked the box on the form which is an assumption that LTFT will be accommodated by the Employing Trust and therefore is an “approval” by default.

There hasn’t been any rejections and unclear on the implementation of this part of the process. No real guidance on approval responsibilities and process.

SW has a documented process with Trainee, Associate Dean and Postgraduate Dean involved, preparing cases statements, with timescales made aware to the parties involved. However, in practice, this has not yet happened as there have been no rejections yet.

For specialty and Dental, there is no monitoring of applications through reports. GP only, uses a tracker spreadsheet.

There is no tangible data on the number of applications received apart from referring to TIS.

There is a gap between Trainee and Trust and Trainee and HEE in the application process in the sense that application may have been submitted (e.g. for Disability) where supporting evidences are still being awaited for but the trainee has already started in the Trust as LTFT and NHS SW becoming aware of this until later. What constitutes an approval, isn’t defined.

An LTFT trainee may have more ARCPs than a full time doctor in training. It becomes a challenge in specialty school in deciding on the progression date/point.

North West

1	There is no definite/defined process of Communication of HEE and Trust around Trainee Rotation planning, capacity planning and Post Funding.
2	Some Trainees do not come to HEE LTFT Admin for guidance on LTFT process but go through the school or Lead employer who THEN contact HEE LO
3	Some Trainees do not check website for information around LTFT but prefer to speak to colleagues, school or the LO
4	Quite a number of forms to complete in this process
5	Only the eligibility form is submitted online but all other forms are paper form and submitted via email
6	Storage is something they need to look at. They have subfolders and spreadsheet to manage. It also go to TIS document section. Retention guideline is 6 years
7	About 5% of trainee do not respond to emails in a timely manner
8	Challenges of requesting for documentation because of confidentiality. The element of trust comes in. No clear rule in SOP
9	Application window exceeds 2 weeks
10	CCT date not mention in application
11	Complex appeal process

East & West Midlands

1	LTFT can’t be controlled by the LO as Trainee can apply anytime. TPD can only Advise Gold Guide states ‘Well founded reasons’
2	The process of discussion with Trust not very clear
3	Some Trainees applies without discussion with TPD/ES
4	The fields are all mandatory but trainee can type in anything to progress the form. So programme still need to check after submission and request more information via email
5	No dedicated team for LTFT. Just the programme team
6	No process for Appeal yet but the TPD should be responsible here not the programme
7	Issue with form around submission on time or late submission; Progressive submission. Still allows submission with missing field

Wessex

1	They can still put their application through without discussing with the TPD and the trainee tick the box in the form that they have spoken to the TPD
2	Please note at this time it is not possible to save a form in progress and return to it at a later time.

North East - TBC

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Analysis & Synthesis of Pain Points in the Process and Considerations for Alpha

The below are some of the suggestions that could contribute to a more streamlined and transparent LTFT process, addressing the current issues and improving the overall experience for trainees.
These could be utilised to set metrics that can potentially be measured against at alpha and beyond, in order to track effectiveness and efficiency of solving the identified problems and gaps in the processes from the Discovery phase.

Theme	Pain Points ☹️ 👿	Suggestions for process improvements to be considered at alpha 💡➡️
Communication, Understanding and Awareness	Trainees find it challenging to understand the relationship between Deanery and HEE (NHSE). Unclear guidelines on the duration of LTFT approval and potential pay implications. Lack of clarity on the revised CCT end date and limited local resources for trainee support. Trainees not seeking guidance from HEE LTFT Admin / HEE websites in the first place, relying on colleagues or schools. Some trainees applying without discussions with TPD/ES. Inadequate communication between HEE and Trusts regarding trainee rotation planning and post-funding.	Develop clear communication channels and materials to explain the relationship between Deanery and HEE to trainees. Provide comprehensive training sessions or enhanced materials to support trainees understand the entire LTFT process, including the roles of different entities involved. Conduct regular training sessions for trainees, TPDs, and other stakeholders on the LTFT process. Increase awareness among trainees about the availability of online resources and guidance and impacts of training as LTFT. Provide support and clear guidance to trainees for calculating revised CCT. Establish a defined process for communication between HEE, Trusts, and TPDs regarding trainee rotation planning and capacity. Encourage early discussions between Trusts, TPDs, Deans, and Local Offices on post-funding and other relevant matters that impacts LTFT.
Application Process	Lack of defined processes for discussing impacts LTFT has on training with TPD/ES. Short notice on application processing leading to complaints from Medical Staffing. Limited control over LTFT process by Local Offices where trainees able to apply at any time without application window/s. Different processes used in different local offices and sometimes also differs by specialty within a Local Office with different roles assigned to the approval	Establish a clear SLA (Service Level Agreement) for processing applications and communicate / make available to trainees. To provide and make accessible to trainees updates on the status of their applications. Explore the possibility of a more user-friendly and universally compatible application form, possibly moving away from the current Word or PDF forms used in most Local Offices.
Forms and Signatures	Difficulty with the Adobe PDF format for LTFT forms, creating compatibility issues. Some Local Offices requiring multiple forms either per specialty or within same specialty for different use cases. Lack of Accessible forms by most Local Offices therefore requiring admin support to complete in cases of accessibility needs. Where an online form is provided, it is not possible to save and return back at a later time. Errors in re-calculating new CCT dates leading to submission with incorrect information. Number of signatures required by some LOs in the approval chain in order to submit an application. Trainees submitting forms with missing signatures, causing delays. Mandatory form fields, but trainees can progress with incomplete information, requiring follow-up and adding delays.	Explore the possibility of creating a streamlined, single, user-friendly, accessible and error-resistant online form for LTFT applications. Ensure that the online form has mandatory fields with proper validation checks to prevent missing or incorrect information. Eliminate the requirement for multiple signatures and complex approval process by establishing clear roles and responsibilities for the approval part that is nationally aligned. E.g. Whether this might mean creating policies that put the onus on TPDs to approve applications nationally following a certain set of criteria.
Categorisation, Triage and Processing	Ad-hoc triaging of applications due to a surge in requests for flexible training. Manual verification and processing of forms leading to delays. Ad-hoc prioritisation of applications due to non-existent or unclear local processes. No differentiation in processing based on reasons such as Childcare/ Disability /Health by some LO’s due to volume. Challenges in requesting confidential documentation. (e.g. OH or GP notes, does BMA warrant the physical evidence of those being disclosed in their entirety? Based on IG rules - You need consent or an alternative legal basis to use a person's health and care information for non-care purposes.)	Establish a standardised triage process & criteria for prioritising applications based on specific criteria (e.g., Childcare / Disability / Health reasons over wellbeing) aligned with/Updating National SOP and GMC Gold Guide to reflect. Establish clear roles and responsibilities for the approval part that is nationally aligned, eliminating duplication and unnecessary admin. Whether this might mean putting the onus on TPDs to approve applications nationally following a certain set of criteria.
Approval, Monitoring and Expectation management	Different processes used in different local offices and sometimes also differs by specialty within a Local Office with different roles assigned to the approval Insufficient monitoring of applications, especially in specialty and dental fields. Lack of SLA published to trainees on processing applications, causing uncertainty for trainees. No transparent way to track application status by both trainees and internally Challenges in monitoring applications, especially when submitted with less than 12 weeks' notice.	Clearly define and communicate the responsibilities and roles of different parties and NHSE LTFT teams in the approval process. Establish a streamlined process that works for all Local Offices along with clearly defined roles and LTFT Team within NHSE . Establish a robust means & SLAs to monitor, track and report on LTFT applications internally. Provide regular reports on application statistics, including the number of applications received and processed.
Data Management, Validation and Reporting	Reliance on manual spreadsheets and moving application forms across local SharePoint folders leading to administrative burden and errors. Mandatory form fields, but trainees can progress with incomplete information, requiring follow-up and adding delays. Issues with shared folders and sync problems for supporting documentation. Lack of tangible data on application numbers, relying on TIS.	Streamline the data management process by reducing the reliance on manual spreadsheets. Consider a more secure and efficient data storage facility to handle supporting documentation and eliminating sync issues.
Rejections, Appeals and Re-applications	Lack of a clear appeals process for rejected applications and managing expectations. Trainees having to reapply due to rejection or submitting applications outside the specified window. Rejections aren’t always following GMC Gold Guide or National SOP guidelines, e.g. application outside window. Rejections based on insufficient supporting evidence without clear guidelines.	Implement an Appeals Process with clear guidelines and a team / resource with defined roles for handling appeals. Consider the implementation of BMA proposed LTFT Champions being involved early in the process to narrow down factors leading to rejections and reapplications. Does BMA warrant the supporting evidences (e.g. OH and GP Notes) being disclosed in their entirety? Depending on the outcome of this, rejections needs to be reviewed if still relevant going forward.
Complexity in Work Pattern Negotiation	Delay in negotiating work patterns until HEE/NHSE approval is received. vs. some Local Offices receiving plans from TPD’s prior to notice being given to HEE. LTFT trainees potentially having more ARCPs than full-time counterparts.	All the points in “Communication, Understanding and Awareness” Consider factoring in clear guidelines for LTFT trainees in relation to ARCP and making the information available and accessible across all channels.
Review and Continuous Improvement	Our observation: No dedicated committee and no joined-up, periodical review for implementation of improvements to the LTFT process nationally leading to local divergences	Consider forming a dedicated team or committee (involving TIS Team members and LTFT leads/ Deans / TPDs / HoS) to regularly oversee LTFT processes and address emerging challenges iteratively. Periodically review the LTFT process, gather feedback from trainees and stakeholders, and make necessary improvements incrementally.

MVP Process - TBD - Submitting an application via TSS for application with a WTE of 50-80% (in increments of 10%)

Note: This is based on the Prototype/Mock-up John O and Naz A have come up with? - https://excalidraw.com/#json=FrTl6GQGtF2lyS_1cCBV5,YGt6nnEmYNhbblRsdVvU7w

Has this MVP process been validated by LO’s, TPD’s, LTFT leads?
Which other options are going to be tested in an alpha?
Processing of applications Questions - TBC
Does it address the pain points above?
What metrics from the discovery are going to be used to measure the success of this MVP process?