Job planning in forensic psychiatry

Forensic Psychiatrists work across diverse settings within or alongside the criminal justice system, including secure hospitals (high, medium, and low secure), prisons, and the community.

The nature of their work requires a carefully structured job plan that ensures sufficient time for safe, high-quality clinical practice with individuals who often present substantial clinical risks.

While specific duties vary, key responsibilities can include:

• Clinical assessment and diagnosis: comprehensive evaluation of mental state and diagnosis.
• Risk management: cyclical assessments and management of risk in patients with mental disorders, including in complex, high-risk cases.
• Treatment of enduring illnesses: management of mental disorders that are, as yet, treatment-resistant and enduring.
• Formulation and treatment planning: multi-source integration of biological, psychological, and social factors to develop holistic treatment plans with the patient and MDT.
• Gatekeeping assessments: evaluating the necessity of secure inpatient care and determining appropriate levels of security.
• Legal and safeguarding frameworks: application of mental health law, including the Mental Health Act, the Mental Capacity Act, issues involving the Court of Protection, and safeguarding processes. Exercising the duties of a Responsible Clinician (when approved).
• Impact of security measures and restrictive ppractices: understanding the balance between public safety, patient autonomy, and rehabilitation within secure settings.
• Victim safety: addressing victim issues and liaising with relevant agencies for victim protection.
• Advising and liaising with the Secretary of State: providing annual statutory reports to the Secretary of State for Justice and making informed requests in relation to restricted patients.
• Clinical leadership: leading multidisciplinary teams and coordinating care across agencies. Modelling a calm and focussed environment within the organisation
• Professional testimony: in legal proceedings, including preparing and presenting evidence at Tribunal hearings and Hospital Manager meetings.
• Out-of-Area placements: clinical review of patients placed outside of their home area.
• Advice and second opinions: providing specialist advice to colleagues and psychiatrists in other specialties.
• Collaboration: collaborating with primary and secondary care teams on the management of co-morbid physical and mental health conditions.
• Expert testimony: psychiatrists may choose to put themselves forward as expert witnesses to give their expert evidence and opinion within judicial processes.

Consultants provide clinical leadership within their teams to ensure the delivery of high-quality care and treatment for patients. In complex clinical cases, involving a substantial degree of risk, effective leadership requires psychiatrists to foster a calm and focused environment within the multidisciplinary team and department.

By modelling clear communication, valuing diversity, exploring differing viewpoints, and promoting collaborative decision-making, consultants strengthen team cohesion and enable the delivery of safe, recovery-focused treatment while upholding patients’ rights and maximising the safety of all involved.

A flexible approach to job planning is crucial for organisations wishing to support psychiatrists in pursuing advanced leadership roles, such as local medical management or regional and national positions. The opportunity to integrate advanced leadership activities within a 10 Programmed Activity (PA) job plan can help to ensure that these responsibilities are appropriately managed, though some psychiatrists may prefer additional PAs to accommodate their leadership commitments.

Forensic Psychiatry is a complex tertiary specialty, with psychiatrists playing a critical role in training related to medico-legal issues, risk, and interfaces with the criminal justice system. To maintain and enhance their own expertise, it is imperative that psychiatristsare allocated dedicated Continuing Professional Development (CPD) time for both their own growth and to provide training to others.

Psychiatrists should be given the opportunity to engage in research to advance the specialty and contribute to the broader medical field. Additionally, involvement in educational and academic roles is crucial for training the next generation of specialists and should be incorporated into job plans. This requires time to develop educational skills alongside time for teaching.

Supervising roles are a key responsibility for psychiatrists. Adequate time must be allocated within job descriptions for supervision, with clear distinctions between psychiatric, educational, and clinical (direct) supervision. For educational supervision, the Royal College of Psychiatrists recommends 1PA per week for supervising up to five residents. The job plan of Clinical Supervisors should allow for at least weekly one-hour sessions of psychiatric supervision i.e., 0.25 Supporting Professional Activities (SPA) per resident. Additional time should be allocated for direct supervision of clinical cases. In forensic settings, resident doctors in training posts should ordinarily review patients from the Consultant’s clinic list, rather than an additional list, to allow the opportunity for direct Consultant supervision over time.

Supervision of other medical trainees, such as foundation and GP doctors may in general resemble the above arrangements, but with consideration of the relevant specialty training guides. Psychiatrists require time to develop and maintain their skills as trainers.

Psychiatrists may agree to the supervision of non-medical professionals as part of a job plan. It is worth remembering that supervision is not the same as ordinary multidisciplinary working. The exact extent and commitment of that supervision should be clear within job descriptions. It might range from supervision of non-medical prescribing to direct or close supervision of clinical cases. Arrangements are potentially highly variable and so clarity around time and responsibility is important. Job plans must have the appropriate level of allocated time: this will be Direct Clinical Care (DCC) time when it relates to direct or close clinical supervision of a case, and it may be SPA time if it is more reflective and general. Many such roles are likely to require both DCC and SPA time.

Unlike doctors, Physician Assistants are dependent practitioners and will therefore require additional direct clinical supervision by a consultant. It is recommended that job plans afford at least one hour of weekly psychiatric supervision per physician assistant, in SPA time, but there must be additional provision for supervision of clinical cases within DCC time. An example of this will be in considering how many patients can be reviewed in a clinic by the consultant whilst also affording sufficient time for detailed and real-time discussions of physician associate cases. Consultants should have a minimum of 0.25 SPA and 0.25 DCC in their job plan for each Physician Assistant supervised, though additional DCC time is highly likely to be required for less experienced supervisees.

Development of Forensic Psychiatry requires collaboration on an international level, and we encourage organisations to allow study budgets to be used for international professional visits, conferences, and training.

SAS psychiatrists job plans should follow the same principle as those for consultants. The College supports 8 DCC: 2 SPA for both speciality and specialist psychiatrists. Amendments to the exemplar 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 and informal educational responsibilities in relation to resident doctors, medical students and other medical and health professionals, the specific time allocated for this in the consultant job plan should be changed into clinical time, including the associated administration linked to it.

Given the diverse nature and locations of roles in forensic psychiatry, job descriptions must account for the time and complexity specific to each post. For example, prison-based roles often require additional administrative time for writing hospital referrals, while inpatient roles demand time for the extensive responsibilities of the Responsible Clinician (RC).

If a psychiatrist’s role involves more than sessional or visiting input to a prison, job planning should allocate sufficient time for all required tasks including responding to clinical queries outside of clinic sessions. Given the unique operational and clinical challenges of a prison setting, which is dependent on the rules and regime of the establishment, particular note should be given to the assumptions described in the table below, with the number of patients booked being adjusted in terms of actual clinic duration and patient availability. This is crucial for ensuring safe and high-quality care.

Many of a consultant’s core responsibilities cannot be delegated to others, either due to legal requirements or the level of knowledge and skill required. In this context, organisations should be mindful when making requests of consultants.

The example recommendations given in the table below take account of the complexity of forensic work, as well as the significant time needed for optimal liaison with external agencies that so often is necessary. Reviews of out of area placements should account for travel time and implications of security arrangements.

Job descriptions should clearly indicate the level of input from other members of the MDT, as well as resident doctors, so that the team composition can be considered within the anticipated workload of the consultant. Models of care that require additional regular meetings beyond traditional multidisciplinary team approaches, should be fully and transparently described and accounted within job plans.

Consultants may agree to be Medical Approved Clinician (AC) to a non-medical Responsible Clinician (RC) Such a commitment will need to be reflected in job planning. There are a range of responsibilities that a medical AC will have in such circumstances, and this will vary according to the competencies of the non-medical RC. For example, because non-medical RCs are not medically qualified, the medical AC is likely to be consulted for situations requiring specialist psychiatric advice such as, for example, physical disorders and how they may interact and impact upon mental disorder. Non-medical ACs, even if they are prescribers, may not be able to prescribe the full range of medication which may require consideration. Non-medical ACs are not Section 12 approved, and all of the tasks associated with this role will need to be undertaken by a Section 12 approved doctor. The Medical AC will need to have a good and up to date understanding of the patient histories and presentation and are likely to attend at least some of the MDT meetings. They also require time for patient assessment, reading of reports, preparation of statutory forms, and consultations related to treatment. Although less than the time required if they were the RC, the role is likely to require substantial regular time within that consultant’s job plan.

While video conferencing technologies are a convenient communication tool, they do not reduce the time needed for clinical contact, treatment planning, or documentation. These tools primarily facilitate collaboration rather than lighten the clinical workload. However, they may offer convenient options for reviewing some out-of-area placements, which is accounted for in our example recommendations in the below table. As technology continues to evolve, there may be increasing benefits in supporting patient reviews at key transition points between levels of security and services. Nevertheless, this convenience could inadvertently lead to higher workloads and greater expectations on consultants. Therefore, careful planning is essential to ensure the effective use of technology without compromising safe and balanced job plans.

We welcome choice for consultants who wish to have flexible ways of working. This may include a preference to work longer hours over fewer days (compressed hours), and consultants who wish to have job plans that are less than full time. We encourage organisations to be flexible and accommodate these preferences as far as is possible.

We encourage employers to value the expertise of consultant forensic psychiatrists who wish to undertake expert witness work for courts. The legal system depends on the availability of experts so that patients can have expeditious and well-advised progression of their legal cases. By allowing consultants to undertake this work flexibly, the organisation also benefits from that maintained expertise including for the essential delivery of training to higher residents. We encourage organisations to allow consultants to time-shift their work, to assess patients and attend Court.

The following table offers some examples of what workload may be expected within a professional activity (1 PA), but we stress that this is guidance only as the nature of tasks and the case-load mix may vary between services. It is based on a standard job description of 7.5 PA of DCC time and 2.5PA of SPA time.

The new Mental Health Act amendments will, in stages, add responsibilities for Consultants. Although these duties are not yet reflected in the proposed PA allocation table of this guidance, organisations should plan for the extra time needed to comply. In practice, this will likely require reduced caseloads, phased in alongside the staggered commencement of the legislation. Future guidance will again review recommendations considering the changes to legislation.

1. In each case the level of time and expertise available from resident doctors and/or SAS doctors will partly determine which end of the range is reasonable – up to 7.5 DCC sessions will be made up from an appropriate combination of the roles given in the table.

   Note: for probity to be maintained, any fee-paying work must be explicitly reflected in the consultant’s job plan. There are a number of example ways this can be organised: time-shifting – up to 1 PA per week could be time-shifted without this interfering with NHS or other clinical activity; a number of PAs can be allocated for work that attracts a fee to be undertaken within the job plan, with fees being paid to the employer; or part-time contracts for consultants to accommodate fee-paying work outside the consultant job plan.

2. Please note that where a forensic psychiatrist provides more than a couple of clinic sessions, and where main role is prison-based rather than visiting/sessional, all aspects of the prison work should be carefully afforded time within the job plan, along with any other roles such as leadership, academic and teaching.

3. The amount of time required for a gate keeping assessment, and preparation of an outcome letter, will vary according to factors such as the complexity of the case, the location (e.g. hospital/prison) and distance of the patient, the quantity and quality of reports and records to read, and whether multiple interviews are required. One standard assessment may take between 1 and 2 days of time (2-4 PAs), but frequently longer for more complex cases. Individual job descriptions should take account of added complexity of cases, and frequency of referrals, when calculating the time required.