First, define the extent of the problem.  Suggest to the scheme administrator a ‘late arrivals register’ separate from the normal attendance register, so that trainees can record what time they arrive and the reason for late arrival.   Also do a ‘late arrivals’ register at the surgery.  Compare the two.  Is the trainee just late for HDR or always late for everything.    If for everything, even practice surgeries, suggest informing the GP Trainer to explore.   If only at HDR but not at the practice, an open and neutral discussion of what is making them late for HDR.  What can be done to rectify this? Remember, the trainee might be trying their best to get to HDR on time, but is struggling because of organisational things at your practice.   (e.g. limiting home visits to a maximum of 1 or 2 for trainees when they have to go to HDR).

• A Practice Manager can do loads in this situation.  For instance, what if it turns out to be something about their conditions of work? 
• So, the first step is always to explore, explore and explore.  And when we mean explore, we mean on neutral territory without the negative emotions you may be feeling about the trainee.   Our desire is to understand and the trainee will only be open and honest if we show them that we want to understand and help rather than criticise and tell off like a headmaster/mistress.  
• You may want to do this yourself or bring it up with the GP trainer and see if they want to explore it. 
• There are loads of reasons why our staff get resentful.  Perhaps they don’t feel respected.  Perhaps they have lost a loved one or something is kicking off at home.  Perhaps they are depressed or anxious.    Perhaps they have financial difficulty and have not been sleeping hence the irritability and resentfulness.  Perhaps they are struggling with being a new parent or have several children that are proving difficult to maange.   There are lots of reasons, and the only way to find out is to explore.    Once explored,  there might be things which could be done (e g family-friendly working hours).
• However, the trainee may also be resentful that their fellow trainee is having it “easy” at the practice down the road.  In this sitaution, it is important for trainees to understand that there will inevitably be variability between the exact working conditions in different practices, which are autonomous organisations.   That is the real world and will be no different when they qualify and apply for a job.  No two jobs are the same. 

Legally, Health and Safety procedures suggest that the patient could be asked to stop smoking, and open all the windows, for 4 hours before the doctor’s visit.   Clearly, this would need good organisational skills in order to avoid unnecessary delay in the visit.   Or the patient could be asked to move to a room where they don’t smoke, perhaps the kitchen or hallway.      Please remember, any health professional has the right to prioritising their own safety.  For example, I don’t have asthma, but I would still insist the patient open all windows and aerate the place.    Why should my lungs inhale their fumes?  Why should my clothes stink of smoke?   Why should I have to put up with the smell of smoke all over me during the rest of my working day?

• First of all, if the trainee is ringing so late, has anyone actually talked to them about the process of informing the practice about ringing in sick?  Perhaps they ring last minute because they want to give themselves some time to see if they can manage coming in.  In other words they want to do the right thing.  But at the last minute they realise they can’t.  Of course, if they knew that logistically it would be much better for the practice to know as early as possible and they can see why, then perhaps that is all that is needed for them not to ring in so late.
• As for the repeated absences, this should be raised with the GP trainer.   Jointly plan a way forwards – which might, in the first instance, be down to the Practice Manager to handle or the GP trainer might take it upon themselves.
• Whoever takes on the role of the first contact to talk about repeated absences, please, please, please remember, the aim is to explore the difficulty.  Do not go in with negative emotions and guns blazing.   We want to understand what is going on here.  It is dangerous to start with the thinking “this trainee is a bit lazy and doesn’t pull their weight”; a very dangerous approach.    We need to first explore and understand.    State matters of fact because they cant be argued with.  “I see last month you were away 4 times”.    And then show that you are here to try things better rather than to criticise and tell off.  “We know as an experienced training practice that often this is a result of something happening with yourself,  back at home, or here at work.  I was WONDERING if this is the case and whether we could talk to see how to make things better for you….”
• Remember, need to keep your emotions in check.  They might be going through a divorce.   Or they might be in financial difficulty and moonlighting and hence the need to be off work at the last minute.  Perhaps they are depressed or have a medical condition like Rheumatoid Arthritis that keeps flaring up.   The possibilities are endless.  One thing is for sure…..  the lazy GP trainee who just can’t be arsed is an uncommon occurence.  
• Remember, the PM should implement the normal practice sickness policy (e g a back-to-work conversation after every episode of sick leave; a formal interview if there are 3 episodes in 6 months; could refer to Occupational Health).
• Don’t forget a referral to their own GP if health issues identified.   Don’t forget that you may need to do a referral to Occupational Health too.   The GP Trainer SHOULD NEVER assume the role of becoming the trainee’s temporary personal GP.
• Trainer should discuss the educational implications and possible need for additional training period at the end of the scheme if more than 2 weeks in any one ST year.
• The Trainer should also discuss the issue with the Training Programme Directors.    The GP trainee should know that they are doing this. 
• The GP training scheme should have in place a continuing sickness and holiday record for each trainee, with continuity from post to post.  Check to see and inform the administrator of each sickness period for your trainee.  This is the role of the PM.

• A good Practice Manager is enthusiastic about GP training as much as their GP Trainer(s).     If the GP trainer feels low about the place of GP training in the eyes of the practice compared to other activities, ask yourself….  is this an organisational ethos that you have perpetuated through actions of your own.  For instance, if other GP trainers or even other members of staff are constantly complaining about something to do with GP training, have you ignored it and let it go by.   Have tensions risen as a result of this.   Or perhaps you have given too much focus on the money-generating activities at the expense of GP training – which then never gets discussed or reviewed.
• So, if this situation arises, we would suggested
• Having an open and honest discussion with the GP trainer on neutral territory.   Just listen, do not defend.   The aim is to understand, not to retaliate or defend.
• Ask yourself about your role in all of this as Practice Manager.
• Discuss with the GP trainer how to make things better.   How do we proceed from this point forwards?
• Arrange a meeting with the practice or doctors, or a relevant group (e.g. admin staff) and structure a session to discuss views.  Educate about the pros and cons of GP training.  Promote shared understanding.  Then try to come up with a shared plan that promotes the ethos with which you wanted to engage with GP training in the first place.  
• (see document under Downloads section on the pros and cons of training)