Job planning in general adult psychiatry

Quality factors

Job plans should make express reference to quality benchmarks, these could be local, regional or national standards such as National Institute for Health and Care Excellence (NICE) quality standards. Accomplishing these standards can impact on Consultant time, for example review patients 2-4 weekly when medication is being changed, and methods will need to be developed to overcome the limitations.

Population factors

The volume of clinical work has grown dramatically since the previous Adult Psychiatric Morbidity Survey in 2007. The latest survey (NHS Digital, 2016) uncovered an increase in common mental disorder rates in women; increase in self-harm in men and women; emergence of young women as a high-risk group with high rates of self-harm, post-traumatic stress disorder (PTSD) and bipolar disorder. There has also been an increase in diagnosing adult ADHD that has an impact on assessments and follow up care as most patients chose to have treatments that require specialist prescribing.

Since the COVID epidemic much has been learnt about health inequalities, the impact on physical and mental health and how to address them.

Understanding and responding to the local population need is important in considering the mental health resource required, including psychiatrists. The local deprivation index indicating the social determinants of mental health include factors such as income, employment, socioeconomic status, education, food security, housing, social support, discrimination, childhood adversity, and the ability to access acceptable and affordable health care will adjust the need in the local area for mental health services.

Consideration should also be given to local “hot spots” of need and the impact on the service – such as bail hostels, supported accommodations and nursing homes.

Understanding and responding to the local population need is important in considering the mental health resource required, including psychiatrists. The local deprivation index indicating the social determinants of mental health include factors such as income, employment, socioeconomic status, education, food security, housing, social support, discrimination, childhood adversity, and the ability to access acceptable and affordable health care will adjust the need in the local area for mental health services.

Consideration should also be given to local “hot spots” of need and the impact on the service – such as bail hostels, supported accommodations and nursing homes.

Staffing factors

Safe and effective working with patients depends on the presence of an effective multidisciplinary team. So the size, clinical seniority and stability of a team will have an impact on the consultant roles and responsibilities and therefore the job plan.

Mental health services are facing a significant recruitment crisis and it is not unusual for employers to rely on locum medical staff and agency nursing staff for service provision. Some of the locum medical staff may not be qualified to supervise junior medical staff and short-term locums are usually not involved in management activities, which will impact on the workload of substantive staff. Some locum consultants may not have AC approval and require a colleague to provide this role.

Agency staff in mental health teams can hamper continuity of care and can be especially anti-therapeutic for patients who have experienced trauma and find building trusting relationships difficult.

Working with colleagues who are less than full time can also put pressure on others within the team as there could be requirements for significant ongoing cross-cover.

The move to electronic patient records and prescribing in many organisations has come with a rationalisation of clinical administrative support. However, with the greater complexity of services and requirements to evidence quality practice, administrators play a vital role in supporting the consultant psychiatrist to ensure they are efficient and effective to carrying out their clinical duties.

All of these dynamic staffing factors should form part of the job planning discussion and indicate the need for interim support while the staffing issue is resolved.

Legislative factors

In England, Wales and Scotland local use of Community Treatment Orders can have a great impact on the workload of Consultant Psychiatrists, particularly those working in the community.

There is great variety in how CTOs are used across teams, services and Trusts that will depend on the nature of the team (CMHT vs AOT) and the complexity of the team’s caseload. Discussion should be had in the job planning meeting about the use and number of CTO and how this impacts on the role. Some roles may require smaller caseloads, less time dedicated to routine follow up as more time is required in Mental Health Act work.

Consultant general adult psychiatrists are key clinical leaders in the delivery and development of mental health services. All Consultants should have the opportunity to develop and use their leadership skills, with training and access to times when they can understand and influence service improvements. The job planning discussion can lead to these developments.

Their involvement in the local health system with partners such as primary care, social care and commissioners is important to play a key role in modelling high-quality patient care, in building continuously drive quality improvement and to ensure that patients have a caring, responsive and safe pathway of care.

Service objectives should be set in job plans to deliver on this with SMART (specific, measurable, attainable, relevant and time-bound) objectives that encourage improvements for the local population health.

The effectiveness of this SPA can be increased by engaging in a team job planning process. Team job planning helps consultants to work together and share tasks, so they can prioritise an area of interest rather covering the many demands as individuals such as smoking cessation, physical health, suicide prevention etc.

Education and training is a fundamental part of the Consultant role to develop their team and prepare the clinicians of the future service.

It is important to ensure that job descriptions take into account the different professions and grades of trainees. For example, foundation doctors may need additional support, especially in a 4-month placement, compared with higher specialist residents. College guidance suggests allocating 30 min per new patient for discussion with core residents/GP trainees and foundation doctors; with time also required to supervision FY/ CT doctors for follow up appointments. This is in addition to the protected weekly clinical supervision time.

When a consultant is required to supervise multiple trainees, consideration needs to be made to the time this will take.

Where the consultant is expected to deliver training to medical students, this will also need to be given the appropriate time to deliver in the job plan.

Many consultants now also provide multi-professional educational roles and supervision – for non-medical prescribers, advanced clinical practitioners, physical assistants. Sufficient time is required in the job plan for all these training activities.

Some consultants also have a role teaching, that will require additional time to providing supervision.

Maintaining psychotherapeutic skills

All consultants need to maintain their psychotherapeutic skills aligned to their clinical role to ensure that they consider the psychological aspects of presentation and management. This might be reflective practice, attending a Balint group or running group therapy. It is integral to the work of a consultant psychiatrist and should be 0.5 DCC in all general adult job plans.

SAS psychiatrist job plans should follow the same principle as above. The College supports 8 DCC; 2 SPA for both speciality 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.

Job descriptions must set out allow the consultant to have sufficient time and support to deliver all aspects of their expected role so allocated sessions will depend on these expectations and the other staff available to undertake clinical and support functions.

A full time consultant should expect to deliver 5 PAs per week of patient facing care in outpatient clinics or community assessments (clinic, home visits and emergency assessments). New patient assessments will require a longer amount of time than a follow up appointment, generally 1 hour for new patients and 30mins for follow up, but this may vary locally depending on the referral process and the complexity of the referral.

Sufficient time in the week should be available for urgent cases, liaison with other professionals when it is members of the MDT who require supervision and support in decision making. How much time and when it is in the week should be agreed with the team depending on when it is most needed. Consideration should be given if patients to be seen outside routine outpatient settings for those who are unlikely or unable to attend. Additional time must be allocated for home visits.

Time will be required to attend MDT meetings, business meetings and governance meetings – how much time will be dependent on the local team and service. It is important to factor in timetable clashes with clinical work that might not allow the consultant to attend regularly.

Consideration needs to be given to the work required to support patients who are on CTOs, as this will be more than for other patients; more frequent reviews for renewal, consent to treatment and tribunals/ managers hearings.

Depending on the organisation of the service and the operation of local forensic services, general adult psychiatrists may have forensic patients as inpatients or community patients and consideration should be given to the Ministry of Justice work that could be required as a result.

All jobs will need sufficient time to complete clinical administration tasks. Most clinicians are reporting a significant increase in clinical administrative duties, including dealing with the rising number of requests for housing, benefits, employment and DVLA reports. Consideration should be given to administrative tasks that could be better done by administrative staff and ensuring consultants are best employed doing clinical tasks.

All community consultant psychiatrist job descriptions must include caseload analysis indicating the number of new referrals, diagnostic or cluster profile of caseload and average numbers of patients on a community treatment order (CTO) over the past 1–3 years. However there is great variation in practice and this should be kept under review as it is likely to change over time.

Understanding the differences in team or consultant caseloads is difficult as even within a service how this is managed can be very different. It is important then to be thoughtful and understand the caseload mix, offering peer group led case load reviews to support with decision making and caseload management could be helpful, including primary care in supporting discharge from services.

In Northern Ireland, patients under promoting quality care (PQC) will need more frequent reviews and multidisciplinary meetings and this should be factored into job plans.

In Northern Ireland, the introduction of the Mental Capacity Act (2016) is likely to have a significant impact on consultant time and this must be reflected in job plans and job descriptions. This cannot be quantified fully at this stage.

Inpatients are the most unwell people in mental health services and should be reviewed personally by their consultant at least once a week. Consultants should therefore expect to input into the ward every day in order to be available for day-to-day decisions requiring consultant input.

There are different models of providing consultant input into inpatient wards. Most wards have a daily team handover where all patients are discussed daily and then either meet with patients as a clinical team or individual clinicians.

All full-time inpatient jobs are likely to require 5 PAs of ward- based clinical activity which are allocated to both clinical team meetings and direct contact with patients. The exact nature of the work will reflect the mix of patients and team members working on the ward.

Clinical care and administrative duties, such as documentation, meeting with relatives, liaising with community colleagues, social care, commissioners and writing reports fill the other DCC sessions in the job plan. Special consideration should be given to time taken in discharge planning and risk assessment as it is of upmost importance that the consultant leads on this and is assured that the discharge plan is safe and robust.

There is a considerable amount of mental health legislation work that is required of inpatient consultants and this is likely to increase with the Mental Health Act review. Consideration needs to be given to the time required in the administration of the Mental Health Act and Mental Capacity Act, preparation for hearings and attendance at hearings, both to present and to supervise residents presenting evidence. Often it is not possible to delegate this work to team members and so the flexibility and availability of the consultant in their job plan needs to be factored in.

Inpatient services often attract training posts for Core and Higher residents and/or SAS grade doctors who are able to undertake medical tasks required with appropriate supervision. The College expects that all inpatient consultants should be supported by a medical colleague on an inpatient ward. The benefit of working with a larger team needs to be balanced with time required for clinical supervision particularly for the most junior residents.

Inpatient services can differ depending on whether they are assessment units, with a shorter length of stay and higher turnover, treatment wards or specialist services. An outline of the ward performance indicators is helpful to ascertain what the consultant will be expected to do in their clinical time – new assessments, MHA work, complex case reviews. For an acute adult ward, a full time consultant can manage 15-20 beds without an additional Approved clinician.

Patients on a Psychiatric Intensive Care Unit will likely require consultant review more frequently than once a week, reflecting the acuity, risks and complexity of the patients. In a psychiatric intensive care unit, all patients are treated compulsorily and hence there is a need for proportionally increased time for mental health legislation work.

The principles set out for community or in-patient care posts apply to mixed posts, with time needed for travel between sites. The advantages of mixed posts are the opportunities for continuity of care. The division of the services will depend on the local need and caseload and is likely to require some flexibility.

A full time Consultant who covers a geographical area is not going to be able to manage the same number of beds or the community caseload as consultants working in one service or provide the same frequency of input into either service as their time will need to be split between the two.

However, any consultant with inpatients should be readily available to the ward staff to discuss issues that might arise with their patients and they should have flexibility within their timetable to be able to attend the ward at short notice if their presence is necessary.

Consultants working in teams intended to provide intensive support to patients as an alternative to hospital admission need to have sufficient time to personally review all patients, or supervise senior colleagues who are, managing such patients.

Time should be considered for travel and home visits as much of the work is likely to be seeing patients in the community rather than office based.

Some consultants manage the whole acute care pathway; both inpatient and home treatment services. There are advantages to such posts because of continuity of care. Time within the job plan needs to be allocated for travel involved.

Flexibility will be required in the consultant’s job plan to be able to attend to community emergencies or inpatient emergencies at short notice if their presence is required. Because of this caseload analysis is important to understand the capacity of the consultant and their team.

Consultants working in assertive outreach and early intervention services will need to spend more time in care planning and less time in routine follow up clinics than colleagues in generic community teams.