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Job planning in intellectual disability psychiatry
Learn about the structure and activities specific to intellectual disability psychiatry and read guidance regarding what would constitute an acceptable job plan.
People with intellectual disability (ID) are more likely to experience mental illnesses and a number of medical conditions than people in the general population. Consultant psychiatrists in intellectual disability (learning disability) are specifically trained to identify mental disorders in people with ID and work in varied clinical settings from in-patient to community services for a variety of organisations in the United Kingdom in the NHS, independent sector, and Local Authorities.
Different terms and conditions exist for those working across the four jurisdictions of the United Kingdom and a multiplicity of arrangements for people working abroad. This guidance cannot possibly cover all eventualities and seeks to create a template by which to quantify the work that could be carried out in a consultant post.
In their training, intellectual disability psychiatrists require experience working with adults, children, and offenders in both community and in-patient services. Intellectual disability services are moving towards delivering care using a care pathways approach where care is delivered and monitored for quality and complexity.
The contributions of consultant psychiatrists in services is greatest when dealing with the complex difficulties that people present with. The consultant psychiatrist plays a pivotal role in how resources are managed through their assessment and understanding of the clinical presentations and risks that people with intellectual disability can pose.
The clinical role of the consultant psychiatrist in intellectual disability involves:
- assessment and diagnosis of mental disorders as they present in people with intellectual disability and their associated treatment
- a deep understanding of the complex factors that contribute to mental disorders – physical, psychological, and social
- an understanding of physical health issues, particularly epilepsy (bronze, silver, gold accreditation) and how both health conditions and their treatment can affect behaviour
- the application of legislative frameworks as they relate to people with intellectual disability
- knowledge of the presentation of mental disorders in people with neurodevelopmental disorders
- understanding risk assessment processes to ensure that clinical risks are appropriately managed
- providing clinical expertise to commissioning bodies and care providers
- health advocacy with other agencies e.g. primary care, secondary care services.
Consultant psychiatrists in intellectual disability assume leadership roles in services, providing:
- clinical leadership to teams
- leadership in service development and service planning with ICBs and commissioning bodies
- leadership in identifying areas of need, introducing new ways of working, learning from incidents or mortality reviews
- leading on ensuring that people prescribed psychotropic medication are reviewed
- leading on ensuring that reasonable adjustments are made for those people with intellectual disability accessing generic services in order to ensure the best outcomes
- leadership in educational roles in services and in the broader NHS
- leadership in the profession through the Royal College of Psychiatrists and other national bodies.
Consultant psychiatrists in intellectual disability provide an essential role in educating colleagues around the intellectual disability and how people may present to the wider health service:
- direct clinical supervision and educational supervision is required when working with residents, SAS psychaitrists and locally employed doctors/ clinical fellows.
- education to non-medical colleagues on the presentation of mental health difficulties in people with intellectual disability.
- Education of medical students attending meetings or clinics as part of their rotation.
Active participation in Academic meetings to ensure that people with intellectual disability and their presentation is understood.
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.
Factors that should be taken into consideration in a job description include the following:
People with intellectual disability require more time in consultations owing to various factors including cognitive and communication problems, short attention span and need for additional breaks. People with ID often depend on carers and professional informants for support and to provide information, that may require multiple discussions. On occasions, behaviour may disrupt appointments, or may require home visits.
People with ID frequently have significant physical health problems, some associated with complex genetic syndromes. They are often prescribed numerous drugs for different conditions that may have interactions, may impact behaviour, epilepsy and mental health. Psychiatrists will often directly manage epilepsy as part of a patient’s ongoing care, or need to advise and support GPs on physical healthcare in relation to some genetic disorders.
A standard community follow-up appointment slot would be 30 minutes and for a new patient 90 minutes (occasionally split if patient does not tolerate lengthy appointments). More complicated new cases (e.g. children, forensic) or autism assessments/court reports can take much longer, in excess of 180 minutes (usually split). For home visits, travel time needs to be factored in.
Catchment population is only part of the picture. The following factors need to be considered:
- inner city v. rural, reflecting density of population, ethnicity, deprivation indices and transient populations
- supported living and residential care arrangements and the quality and training of the care staff employed by the care organisations in community homes
- placements into the area by out-of-area commissioners (or more people moving from rural settings to inner-city provision)
- proximity to local support networks and academic hubs for CPD
- local organisations active in providing quality services (mixed housing projects offering appropriate and good-quality support to those with challenging behaviour, for dementia care, autism, sensory impairment, employment, day service), and availability of other supported activities
- the commitment of local authorities and health commissioners to support intellectual disability services
- arrangements for admission to assessment and treatment beds for those who require more support than can be offered in the community
- Local Residential Colleges that support students between the ages of 18 – 25 who accept students that require term-time review.
The number of consultants required reflects the local configuration of services. Factors to consider include:
- expectations and roles of other mainstream mental health services
- clarity on eligibility criteria to services
- cut-offs in terms of degree of intellectual disability (there is an exponential rise in the number of patients who move into borderline intellectual disability)
- age boundaries or lifespan services
- discrete community/in-patient ‘functionalised’ post or split roles both in the community and for in-patients
- well-resourced supporting teams including secretarial and other allied professions: community nurses, speech and language therapists, occupational therapists, dietitians, psychologists and physiotherapists
- Support from junior medical staff (psychiatrists in training)
- Support from IST and Forensic ID teams
- the availability of resources of specialist expertise in their teams eg (epilepsy, challenging behaviour, autism)
- whether all clinicians are employed by the same organisation and their roles are determined by the same eligibility criteria
- pooled budgets and co-terminous criteria with Social Services; if not existent, health professionals may be working in isolation with some people
- direct case management expectations for complex or high-risk patients
- out-of-area quality assurance roles (post-Winterbourne View) – commissioners may require assessment and management of clients placed out-of-area.
Assuming that there is an adequate team in place, the following are guidelines on what might be expected of a consultant post.
| Activity | Required time allocation |
|---|---|
| New patient assessment | 90 mins |
| Complex cases | 120 mins |
| Where these are performed by a psychaitrist, a pervasive developmental disorder assesment with diagnosis | 240 mins |
| Routine follow up | 30 mins |
| CPA/PQC review or vulnerable adults meeting | 60 mins (more if MAPPA or forensic issues) |
| Weekly team meeting | 120 mins |
| Mental health legislation work including assessments | 120 mins |
| Managing community treatment order patients: managers and review tribunal meetings | 120 mins each at least yearly (more if regular recall) |
| Report preparation | 4 hours |
A WTE community post might expect to carry an active case-load of 100 patients, with 30–40 new referrals each year.
One WTE consultant for up to 12 acute beds. The unit would need a well-resourced multidisciplinary team including social work involvement and additional medical support (e.g. 0.5 WTE specialty doctor or 1 WTE CT3).
Legal reporting standards have increased considerably. Time is required for face-to-face contact with teams and tribunals, as well as patient-related direct and non-direct activity.
In-patient posts: high secure, medium secure and low secure settings
For forensic intellectual disability bed-based services, a full-time consultant could lead services with:
- 15 – high secure unit beds with national assessment duties; or
- 12 – medium secure unit beds and regional assessment duties (there may be scope for regional court work, local community liaison links and advice; local prison sessions may require additional support); or
- 15 – longer-term rehabilitation style low secure unit beds as well as regional court work, local community liaison links and advice; prison sessions may require additional support.
The role to include:
- liaison links
- risk assessment support to local consultants in existing community services
- direct case management for a small number of higher-risk individuals
- court diversion
- in relevant jurisdictions, possible role in managing forensic community treatment orders/Section 37 guardianships and previously compulsorily treated/restricted patients resettled into the local community.
- specialist forensic out-patient activity.
Making some allowance for time required to travel, 1 WTE consultant for non-residential services could support:
40 new referrals per year:
- one direct contact of 2 hours
- indirect contacts of 6 hours in total
- report preparation and liaison of 6 hours.
80 out-patient follow-up visits:
- two direct contacts six monthly (one annual CPA/PQC)
- 72 indirect contacts.
liaison and consultancy to intellectual disability and forensic teams:
- monthly meetings with four area intellectual disability teams and two medium secure units’ minimum.
There are few dual-trained child and adolescent and intellectual disability consultants. Many child and adolescent specialists trained in intellectual disability are now working within joint child and adolescent services. Many new post appointments may be general child and adolescent consultants who have had ‘special interest’ sessions taken in intellectual disability (some lasting a full year). Some may have had no or very limited intellectual disability experience.
There is a need to ensure that where there are split posts (mainstream with intellectual disability sessions), these clearly state how the intellectual disability sessions will be protected, so that patient care is not compromised.