Job planning in addiction psychiatry

• assessment, diagnosis, and management of people with addiction problems as well as those with mental illness, across a range of settings incorporating this into a robust person-centred biopsychosocial formulation and considering the best evidence-based approaches to address the acute intermediate and longer-term goals of any individual client whilst taking into account their capacitous choices and considerations of obligations under the care act and the Mental Health Act.
• extensive clinical expertise in addictions, with the ability to integrate mental health, physical health and addiction disorders.
• expert in a wide range of treatments for addictions, including pharmacological, psychological, and behavioural.
• Ability to assess and manage complex or high-risk people, including but not limited to antenatal and postpartum, and other complex groups which fall within the expertise of the addiction psychiatrist in the context of their specialist registration and any other areas of expertise.
• particular expertise in diagnosing and managing comorbid mental Health and addiction disorders (COSUM as per terminology at time of writing this document).
• expertise in complex prescribing delivery of novel or emerging treatment approaches for the treatment of addiction including risk balance decisions on legacy prescribing practices for longer term clients receiving medically assisted maintenance and recovery to a harm minimisation approach.
• clinical supervision to a range of medical and non-medical practitioners involved in Prescribing, Psychosocial and mental health interventions.
• providing addiction advice and liaison to general practice, other specialties within Psychiatry and medical/surgical specialities in hospital and community settings including interface with chronic pain management. either directly or in conjunction with local liaison psychiatry arrangements.

• leading local clinical governance, client safety, quality improvement, and innovation in substance misuse services.
• being the designated medical practitioner for NMP trainees. 
• liaison with commissioners to define and improve outcomes. 
• assuring implementation of national guidance and standards in substance misuse. Providing clinical input into commissioning and procurement exercises, for example making valid assessments of need, through to setting and monitoring appropriate standards. 
• developing partnerships between different provider organisations.

This will cover a range of grades and professions dependent on service configuration including but not exclusively:

• Medical Students
• Foundation Doctors
• Core and Higher Psychiatric/GpVts residents in addictions.
• SAS doctors
• GPwsi doctors working within the treatment system
• non-medical Prescribers
• team members
• external agencies requesting additional training or teaching.

Consultants should be actively encouraged and supported in supporting training and development of addiction psychiatrists within their role to assure future workforce development.

Where medical residents are clinically supervised by consultants, It should be recognised that their inclusion in clinical activity must be commensurate to their grade and clinical activity is in the context of learning and development need and not to be considered as service provision in the context of expected targeted activity.

Consultant addiction psychiatrists will be actively involved in commissioning, contract performance management, contract variation and tendering processes as they occur. Supporting and leading clinical aspects of service delivery as part of the local delivery team. It would be expected that a proportion of SPA time would be allocated in job plans for this function. 

For SAS jobs to gain college approval they should adhere to the broader guidance related to job plans and broader agreed ratio for DCC:SPA with activities categorised as per examples above for community posts.

SPA time should be ring-fenced to allow for productive use of this and due consideration and encouragement should be given to allow for further career development to include adequate time and resource for meaningful supervision outside of clinical case supervision ( a DCC activity) and to encourage career progression if desired to consultant grade either through supporting in obtaining membership of the royal college and higher specialist Training or to consider alternative routes ( e.g. Cesar or emerging credentialing opportunities).

It is recognised that the SAS role incorporates a range of experience and expertise and requirements and supervision available to those in SAS roles should be commensurate with their level of training, experience and expertise and this to include being allocated supervisory roles to other professionals where they have the relevant training and infrastructure to support this work.

It is recognised by the College that working patterns and indicative timetables will vary from role to role and individual negotiated circumstances of the employed consultant as jobs become more flexible to allow for reasonable adjustments, work life balance and to adapt to increasing consideration of ‘portfolio’ career options. Therefore an ‘indicative timetable based on a ‘9-5 Monday Friday working pattern’ has not been included with emphasis placed more on types of activity in the context of DCC vs SPA and retaining fidelity to the number of sessional PAs as agreed in the contract though this would be open to negotiation as part of annual job plan review.

The College faculty has placed no formal limits on case numbers, service numbers are ordinarily defined by the commissioners, and this will vary dependent on service and support infrastructure. But this should be kept under regular review and allow the consultant to adhere to GMC Good Medical Practice in terms of oversight and assurance for patients under their care. In this context, services will have clients accessing clinical interventions where direct oversight of consultants or medical prescribers may not be required for more straightforward cases, it would not be unreasonable to consider an agreed number of face to face indicative contacts.

Allocated DCC activity should reflect the expertise of the consultant role with emphasise on managing complexity and provision of assessment and reviews for the most complex clients seen within the service. It should not be expected for the consultant role to be focussed on assessments for routine targeted activity and capacity demands outside of exceptional circumstances. Flexibility should be provided for time taken per assessment and review to reflect complexity, but a baseline expectation would be 1 hr for a new assessment and 30 minutes for follow-up appointments to reflect the complexity and allow adequate time to assess the complex biopsychosocial needs and risks of any individual.

A consultant addiction psychiatrist will work alongside other prescribers, Clear governance and accountabilities should be identified as to who holds specific accountability for prescribing within the system and that sufficient DCC sessions is apportioned to ensure appropriate time for robust clinical supervision of other prescribers in the system. It should be recognised that best use of a consultant’s time and expertise is in provision of robust responsive and accessible supervisory and governance support to prescribers and teams to empower guided decision making, as well as the management of potential risk aspects in any delivery of treatment interventions, as well as early involvement in complex cases for guidance and consideration of escalation as required.

Where consultants are working in an addiction service which is not specifically commissioned as a Dual Diagnosis/COSUM Service commissioned to provide mental health care coordination, it must be explicit that the addiction psychiatrist would NOT provide an RO (responsible officer) function for clients under the care of the service who have or are later identified to have secondary care level mental health needs. As per NiCE and COSUM guidelines such clients will be supported with their substance misuse needs but ongoing care coordination and mental health needs would be the responsibility of the appropriate community mental health services and not ‘default’ to the addiction psychiatrist working in a complementary role. There would however be an expectation of close working and liaison with relevant secondary care community/crisis and liaison services to support transitions of care boundaries and to advocate for clients not in receipt of appropriate interventions.

The College and Faculty welcome the opportunities and flexibility provided by remote and online working both in terms of job role and accessibility to clients of senior assessment and review when covering dispersed catchment area. This is to be delivered in line with existing Royal College and GMC Guidance on remote and online working best practice. It must however be recognised that any client under a service will need at times an in-person/face to face assessment and reviews with the team consultant. Complex clients cannot universally be reviewed and managed exclusively through virtual contacts and so any post which does not include an agreed commitment to in-person reviews would not be approved.

There would be an expectation for the job to maintain fidelity to 7.5:2.5 DCC SPA apportionment and equivalencies for less than WTE working as a minimum SPA requirement. This could increase depending on the specific SPA requirements of the post.

DCC examples

• F2F/ Virtual Clinical Activities
• MDM
• Clinical Supervision of Doctors and NMP/AHPS
• Clinically related Admin/Letters/Communications
• Review and prep/signing of prescriptions
• Other Clinical Meetings/ care planning reviews
• Clinical case discussions 
• Travel Time associated with Clinical activity off main site. Within contracted hours

SPA examples

• CPD
• Clinical Supervisor/ Educational supervision/CBD provision 1hr per trainee per week. CBD 1hr per case discussion
• Appraisal Activity
• Service-related Operational and governance meetings Inc DRD/Mortality meetings
• Case Conferences/ learning events, group teaching
• Qi Projects not otherwise covered through additionally contracted worK

It is recognised that teams may be configured and commissioned in a way where administrative support may sit across organisations.

That said dedicated named administrative support/medical administrative support who can work to a level and function of a medical secretary (AFC band 4 administrator) should be available to support the administrative and organisation/diary planning needs of the consultant to maximise efficiency.

The community role particularly in dispersed regions do not easily lend themselves to job planning and activity based on a single site of delivery. This being the case contingencies should be in place to cover the requirement of urgent and or prompt provision of prescribing continuity and or re-titration of OST and or other medically assisted interventions which should not be solely reliant on the presence of a Consultant Psychiatrist to physically be present at a given location to sign and make logistical arrangements for provision paper prescriptions. When working remotely, there should be access to prescribers who can conduct this function and or act under consultant guidance where deemed clinically urgent. 

Where equivalence cross cover arrangement isn’t feasible between Addiction Consultants, clear provision must be available for appropriate experienced and trained cover to be available to support standalone consultant roles either through competent Consultant cover within the organisation or through provision of direct cover for planned or unplanned absences. 

In-patient provision may be delivered either through the NHS through Specialist treatment units, through Third/independent sector provision or a hybrid model of delivery.

Clear governance structures must be in place depending on the commissioned arrangement and relationship to the Unit and the Addiction Consultant Psychiatrist who would be responsible for clinical decisions relating to the patients admitted to and discharged from the unit.

Support resources in terms of staffing medical/non-medical and out of hours provision should be in place as agreed through commissioned structure in accordance with local and or national guidance for in-patient provision.

This should include:

• supporting medical staff, residents and SAS doctors working supporting the provision
• nursing provision and support staff
• specific plans and protocols for out of hours cover arrangements and local access to emergency medical or psychiatric Interventions outside of the skills and resources of the In-patient Unit including Escalation processes and relevant roles and responsibilities between medical staff and unit operational management staff/lead nurse AHP.

Staffing should consider the number of beds, expected throughput/flow and levels of interventions commissioned to be provided in the environment. And in Keeping with current approved guidance for Inpatient Provision.

Activity in the context of DCC/SPA would retain fidelity with the categorisation of activity and 7.5/2.5 split based on a wte post and modified as appropriate for less than WTE commitments.

Guidance in the context of approval for liaison psychiatry approval will be covered in the relevant section of this document for liaison psychiatry.

Where consultants are working in conjunction with or part of a liaison psychiatry team clear roles responsibilities and cross cover aspects should be incorporated and where consultants are working outside of their roles on the specialist register that there are assurances around support structures and training/supervision when assessing and managing clients outside of their specialist area of practice.

In keeping with work life balance and to encourage a diverse and representative workforce, strong consideration should be given for out-of-hours work to be considered as an optional commitment rather than a contracted expectation of the role It is recognised that this is not routinely an expectation for consultants working in the third and independent sector and as such this should be reflected within NHS consultant roles.

It should also be recognised that many addiction psychiatry posts are stand-alone consultant posts, without routine availability to cross-cover availability.

Where this is the case If out-of-hours on-call commitments are part of any planned role, this should include provision of adequate cover options through the existing clinical workforce such that if adequate rest is not attainable, that no planned care activity is expected the subsequent day that would impact on targeted activity or complex cases where cancellation or lack of equivalent expertise is available to carry this activity out i.e. College approval will not be contingent on an on-call commitment but will need to maintain their A/C R/C and Sectional 12 (2) approval status and will need to engage with the relevant requirements to retain these.

Where posts are offered at less than WTE or consideration is given to portfolio job descriptions, sufficient time allocation should be afforded in the context of DCC: SPA for agreed sessions attached to the post for role specific activity.

Clear lines of accountability will be required to include RO responsibilities and relevant appraisal/revalidation aspects to cover the full scope of the consultant’s work in Line with GMC appraisal and revalidation requirements.