Job planning in child and adolescent psychiatry

In addition to the general roles set out above, a consultant child and adolescent psychiatrist will have specific expertise in the following areas:

• Carrying out complex clinical assessments including components needing specific expertise (i.e. a comprehensive developmental history) and identifying and managing physical health problems in children and young people jointly with primary care and paediatricians.

• Management of complex clinical information from many sources to formulate management of medication, therapeutic approaches for the child/young person and family, and therapeutic/consultation approaches within the child’s/young person’s network.

• Knowledge of adult mental health – child psychiatrists are well placed to identify mental health concerns in parents. While it would not be expected for them to directly assess and treat parents, they are well placed to liaise with primary care or relevant adult mental health services, with the consent of that person. In addition, their adult mental health training and experience enables them to support transition of young people to adult mental health services, usually at age 18 (although there may be local service variation).

• Specialist knowledge of interpersonal and systemic dynamics – assessment and management of family, care network, educational and support system issues.

• Knowledge and skills in outcome measurement and evidence-based practice – this will enable the consultant to lead the monitoring of the effectiveness of interventions.

• Managing clinical complexity and severity through direct clinical assessment/treatments, case management and consultation.

• Managing complex information, including knowledge of mental illness,child development, interpersonal/family dynamics, Children’s Act legislation, criminal justice, mental health and mental capacity legislation, to reach decisions in the best interests of children and young people.

• Making child safeguarding referrals, attending safeguarding meetings, preparing reports and documentation and participating in multi-agency meetings in the area of legal and policy guidance around child safeguarding. This area has become more complex over the years and time has to be identified clearly in consultant job plans to undertake those tasks, which includes flexibility needed to respond to urgent situations at short notice.

• Taking part in and attending care programme approach(CPA) reviews, other care and treatment reviews(e.g. CeTRs in England) and looked after children (LAC) meetings, including children and young people admitted to inpatient units or placed out of area (either in health or social care placements), all of which have increased in recent years. Time needs to be identified for these tasks in job plans.

• Supporting the emotional development and early identification of neurodevelopmental and mental health conditions in infants and the under 5 years olds.

• Assessment and advice to social care and youth justice with regard to the developmental, mental health and welfare, and criminogenic needs of children and young people.

• Prescribing will be a part of the Consultant’s role, but not solely: they have a tremendous variety of clinical skills and training, and application of a biopsychosocial model to inform comprehensive assessment and treatment for children and young people.

Consultant child and adolescent psychiatrists will have an inherent leadership role within their clinical teams and services, even if they do not have a formal leadership job.

• Communicate with commissioners in health and other sectors about population needs,mental illness prevalence, best treatment strategies and service design to meet the developmental and mental health needs of children, young people and their families/carers.

• Advocate for the mental health,educational and care needs of young people as well as the prevention of distress and disorder and promotion of emotional well-being.

• Carry out specific leadership roles in medical management, academic roles, roles in medical education and national roles, for instance for the Royal College of Psychiatrists and in a national advisory capacity, as applicable. Some roles, such as Deputy/Chief Medical Officer (CMO) or Medical Director would have a separate job description and job plan, whereas other tasks e.g. RCPsych would fall under the usual consultant contract and additional responsibilities or SPA time, and would be agreed as part of the job plan negotiation locally.

• Governance tasks should also be factored in to the job plan, including the investigation of incidents and complaints, which are often tasked to consultants and can be time-consuming.

SAS psychiatrist job plans should follow the same principle as above.

The College supports 8 DCC; 2 SPA for both specialty and specialist psychiatrists. The model job plan for SAS psychiatrists should reflect the 0.5 SPA difference, which should be added to patient facing DCC.

If the SAS doctor does not have formal or informal educational responsibilities in relation to resident doctors, medical students and other health professionals, the specific time allocated for this in the consultant model job plan should be added to DCC activities for either patient reviews or for liaison with families/carers/other professionals in relation to patient care as appropriate to the service and their role in the team.

Assessments and work with children and young people take place in the context of the family/care environment, as well as educational and professional networks. Multiple sources of information are required.

The child/young person as well as family and other key informants will need to be interviewed. More than one patient may be the focus of referral within a family. Full assessment may require joint interviews with social workers, youth justice workers and allied professionals. It may involve visits/observations within the home, school or other settings, as well as assimilation of assessments by other professionals, for example, psychometric or neuropsychological assessments. Some of these tasks can be carried out and supported by other members of a MDT and would not be expected to be done solely by the consultant.

Child and adolescent psychiatry covers the full range of psychiatric disorders: including conditions specific to childhood, substance misuse, forensic psychiatry, intellectual disability, neuropsychiatry and liaison services. Many adult mental disorders start in childhood or adolescence, and mental and physical comorbidity is often present. There is focus on maximising developmental potential, resilience and social/educational function.

The nature of referrals and service demands will vary depending on local arrangements, and whether an individual service is designed to address a wide range of problems or more discrete diagnostic groups (e.g. substance misuse, intellectual disability, autism, attention-deficit hyperactivity disorder). Complexity of clinical presentation will also vary, with factors such as demographics, deprivation indices and service provision (local community team v. regional or specialist services) being of relevance.

Consultations to other professionals and agencies form a significant part of the child and adolescent psychiatrist’s work. These consultations can last between 15 and 90 min and can take place in a variety of settings. Time to travel to external consultations should be factored into job planning, which may vary depending on local geography.

A standard community follow-up appointment would be 1 hour and for new patients 90 minutes minimum, with additional time needed for required paperwork. More complex cases (e.g. neurodevelopmental assessments, childcare-related assessments or assessments for the criminal courts) can take longer, in excess of 180 min, often over two to three appointments. Uncomplicated reviews may be shorter.

Factors within the catchment area to consider include:

• deprivation indices
• inner city vs. rural and very remote areas
• ethnicity
• transient populations
• presence of children's' homes, specialist schools and secure settings
• nature of other children’s services in the area (e.g. the size and remit of the community paediatric, intellectual disability, challenging behaviour services; provision of parenting, early intervention, safeguarding services by other agencies).

There are many different consultant roles within child and adolescent psychiatry. Community jobs can include, for example, sessions dedicated to sub-specialties (intellectual disability, neurodevelopmental, liaison, substance misuse, etc.). The size and skill mix of the medical staffing and supporting multidisciplinary team vary considerably. This will have an impact on the nature of work a consultant will be required to undertake, including a need to provide consultation to and joint assessments with team members, clinical supervision to medical staff and collaborative work with other professionals and agencies.

In principle, the Consultant should not usually be holding cases alone: they should be co-worked and shared with other clinicians in the multi-disciplinary team and/or have a separate Care Coordinator. The role of the Consultant is more around offering consultation to a team and network, and time should be allowed for this important part of the role in the job plan. This is a particular aspect of the child and adolescent psychiatrist role due to the nature of MDT working and working with schools, social care etc. It is suggested that at least 1PA is needed per week for consultations to a team + 1PA to the wider network of children and young people’s services.

Engagement in service development, strategic planning and team management/leadership will vary in response to local structures and expectations, with an impact on time available for direct clinical work, and time should be allowed for this within job plans. Engagement as case manager, with liaison, networking and administrative responsibilities for individual cases, will also vary.

On-call arrangements vary. Job descriptions will need to reflect the demand and potential for direct clinical work, particularly for consultants who are first on call (i.e. where there is no trainee, specialty or resident doctor as first contact).

Jobs that entail split roles, for example working across two clinical teams, will require additional non-direct clinical time to safely provide input to both teams. This also applies to roles that cover larger regions rather than discrete catchment areas.

Assuming there is an adequate number of consultant child and adolescent psychiatrists in an area and an adequate team in place, the following are guidelines as to what might be expected of a reasonable weekly workload for a full-time consultant with no additional educational, leadership or management responsibility roles. This summary is indicative and for guidance purposes only. It will need to be adapted according to local needs, local structures and work patterns, and to accommodate any additional roles, including supervision of doctors in training (adequate time for training must be included in the job plan) and travel.

There is such variation in types of job role within the specialty and variation in services that it is difficult to give recommended numbers for caseloads. For example, a specialist service such as early intervention for psychosis may have low caseloads but higher intensity; vs. an ADHD clinic might have high caseloads; vs. liaison role would have a transient but complex patient group. This should be discussed locally according to job role and service needs, and agreed collaboratively in an individual consultant’s job plan, to consider the type of clinical role, risk, complexity etc.

Caseloads should be determined through a robust job planning system which takes into account number of assessments, complexity of patients, review appointments, and consultation appointments to ensure that the consultant has an effective case load number which should be seen as a ceiling not a floor. The vital consultative role should be included as DCC in addition to work on an allocated caseload: to include reviews, consultations to MDT or networks and assessments that may not lead to ongoing direct support. It is likely that 2 sessions a week (pro-rata for less than full-time) will be required for consultation given the make up of a multidisciplinary team and multi-agency networks. Flexibility will be needed in the division of PAs depending on the number, risk and complexity of a caseload at any given time.

Clinical admin needs to be allowed for within DCC time. There is a particular admin load for the Consultant Child and Adolescent Psychiatrist e.g. increased requirement for networking compared to other specialties. Also, they are likely to need to write more letters than other MDT members e.g. need to write a letter each time medication is changed, vs other MDT members may update the GP only once per 6 months. In principle, clinical admin time is likely to equate to the direct clinical time again.

Consultant child psychiatrists would not usually do the initial assessment in a service: new referrals would usually be seen for an initial assessment by another MDT member who refers on to psychiatry internally if required. It is important to ensure the Consultant sees the appropriate patients in the service who really need their skills, experience and training e.g. due to risk, complexity, and/or medication requirements.

In principle, the Consultant should not usually be holding cases alone: they should be co-worked and shared with other clinicians in the multi-disciplinary team and/or have a separate Care Coordinator.

Given the huge variability in roles and services, it is not possible to specify precise splits of DCC and SPA sessions. However, the following serves as a guide for which particular tasks should be considered as part of these PAs for a child and adolescent psychiatrist (in addition to the general DCC/SPA guidance in the introductory section of this document):

Direct clinical care (DCC)

• Direct clinical work with children, young people and families
• Clinical work includes emails and telephone calls in relation to cases, as well as any clinical administrative tasks, including letters, reports, completing forms.
• Consultation to the MDT and wider network is a core part of the role and requires more DCC time than other specialties.
• consultations around safeguarding and key legislation to MDT and networks
• includes joint clinical appointments with residents on placement: as even higher residents may be new to child and adolescent psychiatry, they are likely to need more direct clinical shadowing and observation
• Family work is a core aspect of the work of a child psychiatrist, with more time needed for direct clinical work and liaison with families, parents and carers.

Supporting professional activities (SPA)

• Weekly supervision with resident doctors.
• Ensure remain up-to-date with key relevant legislation e.g. safeguarding, Children Act.
• Service development activity in local area.

There would need to be a local conversation and negotiation around the particular local circumstances and skills of that consultant to agree this.

The individual consultant case-load will vary considerably depending on local need and it is therefore not possible to specify numbers in general. The expectations of an individual consultant should be negotiated locally taking into consideration the type of service, complexity of cases, nature of the clinical work, skill mix of the team and other factors as described earlier. A lower caseload would be appropriate for consultants engaged in a highly complex or high-risk clinical patient group, or where there are less than adequate consultant or multidisciplinary staffing numbers or skill mix. A higher caseload would be appropriate for a patient group of predominantly uncomplicated medication reviews.

An indicative reasonable workload for a 10PA consultant would be 1-2 ‘new to psychiatry’ cases per week pro-rata, but not usually personally completing a whole new assessment (which usually involves more paperwork and liaison): as above, this would more appropriately be done by another member of the MDT.

They would also offer a number of follow-up slots, including individual interviews, family meetings, case reviews, but could also include network meetings, consultation, safeguarding meetings, etc. Additional individuals and families are likely to be seen as emergency and unpredictable cases. This would include psychiatric assessment of cases held by other team members. Many community CAMHS consultants will also need to work with acute hospital services for children and young people admitted to hospital, including to provide responsible clinician (RC) cover under the MHA, especially as many acute paediatric services do not yet have CAMHS-Paeds liaison services.

Owing to the variation of service design, funding arrangements and multidisciplinary teams, it is difficult to recommend numbers of consultants in relation to population numbers. As above, due to the variation of services, DCC and SPA figures are indicative only and should be negotiated locally in terms of the precise job plan, although the child and adolescent faculty strongly supports the split of 7.5 DCC and 2.5 SPAs for a full-time consultant.

The job plan should allow for daily ward visits by the consultant, at least a weekly face-to-face review of each patient, team meetings, complex case review meetings and sufficient time for liaison with families and other agencies.

The case-load, using bed numbers as the currency, will vary depending on the nature of the unit, number of urgent v. planned admissions, and skill mix of the staffing complement. An indicative case-load for a 10PA psychiatrist is 10-12 beds (RCPsych QNIC standards recommend 1 WTE consultant for a typical 12 bedded unit). For a unit entirely focused on emergency admissions, the caseload will be lower. For a unit operating in a less acute setting or with many planned admissions, the case-load may be higher.

The designated whole-time equivalent (WTE) consultant time may be adjusted slightly up or down depending on acuity of presentation and age range of the patient group, presence of non-consultant grade psychiatrists and availability of experienced senior multidisciplinary team members.

Services that provide specialist assessment and treatment, often via a liaison and consultation model (e.g. national specialist services, community forensic psychiatry, FCAMHS), on a regional or national basis require a different job planning approach.

Although direct assessments are an important component of this work, the significantly greater proportion of indirect contacts (discussion with professionals via telephone or face to face, including professionals’ meetings) needs to be recognised.

Services of this type are often provided across wider geographical areas and by their nature provide for children and families with needs in multiple domains, with multiple accommodation histories, high-risk profiles and often in complex legal systems.

Specific recognition of the greater travel and background reading involved is also required.

Paediatric liaison refers to the psychological/psychiatric care of children and adolescents in paediatric settings who:

• present with an acute physical health illness (e.g. asthma) and have a comorbid mental health illness (e.g. anxiety) that makes treatment of the acute physical health illness difficult
• present with an acute / chronic physical health illness (e.g. diabetes / encephalitis) and develop symptoms or signs of mental health illness
• present with physical health symptoms but where no physical (organic) cause is found for the symptoms (e.g. non-epileptic seizures)
• present with acute mental health illness.

Paediatric liaison work is therefore not just child and adolescent mental health services providing in-reach support to paediatric services (wards, outpatients or emergency departments) for children and adolescents presenting with acute mental health illness or in crisis.

Paediatric liaison is integrated work between mental health and paediatric services to provide timely concurrent physical and mental health care to children and adolescents.

An infant psychiatrist is a specialised psychiatrist who focuses on the mental health and well-being of infants and very young children.

They assess, diagnose, and treat mental health conditions, developmental concerns, and behavioural issues in the early stages of life. The role involves working closely with parents, caregivers, and a multidisciplinary team to provide comprehensive care.

By providing early intervention and support, infant psychiatrists contribute to the overall health and resilience of infants and their families with positive lifelong effects.

Key responsibilities

1. Assessment and diagnosis

• Comprehensive assessments of infants to understand their emotional, social, and developmental well-being.
• Diagnose and treat mental health disorders and developmental challenges in infants.
• Consideration about impact of parental genetic and environmental factors including use of substances or pharmacological treatments during pregnancy.

2. Therapeutic interventions

• Treatment plans for infants, incorporating psychotherapeutic, systemic and medical interventions based on evidence-based practices.

3. Collaboration with parents and caregivers

• Work closely with parents and caregivers to understand family dynamics and provide strategies and support in fostering a healthy and nurturing environment.

4. Team collaboration

• Multi-agency and multidisciplinary collaboration to discuss complex cases and provide coordinated care.

5. Education and training

• Provide education and training to parents, caregivers, and other healthcare professionals on infant mental health topics.