Job planning in old age psychiatry

• leading the development of clinical standards and implementation of national guidance in old age psychiatry.
• development and monitoring of outcome measures for patients in old age psychiatry.
• working with PCNs/Primary care to deliver services (please see ‘Community Mental Health Framework’).

• Assessment, diagnosis and formulation of management plans with patients and carers for both functional and organic illness in the elderly.
• Expertise in the management of psychiatric illness in patients with complex and/or multiple physical disorders. On occasion this may include patients under the age of 65 who experience physical frailty.
• Expertise in pharmacological, psychological and behavioural interventions to manage behaviours that challenge in the context of a dementia diagnosis, including patients in long-term settings.
• Particular expertise in the diagnosis and management of delirium.
• Expertise working in varied settings, including residential/nursing homes, general hospitals and patients’ own homes and psychiatric inpatient ward, with multi-professional and multi-agency teams.
• There is an increasing number of older adults presenting with Complex Emotional Needs, Eating disorders, Autism and ADHD, Substance Misuse and Personality Disorders and the Consultant in Old age Psychiatry has an important role in their management.

SAS psychiatrist job plans should follow the same principles as below. 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.

• In old age psychiatry services, there are many different models of service provision, ranging from highly centralised services, in-patient units on general hospital sites and well-resourced specialist memory service assessment, through rural services with admission beds on several different sites, to memory assessment services incorporated within mainstream out-patient clinics. Consultants work with a broad range of multidisciplinary staff and often away from their administrative base.
• In addition to expertise in mental health legislation, knowledge of capacity-based legislation is required and time to implement these is needed in all job plans. In relevant jurisdictions, this may include roles as Approved Clinician status, Deprivation of Liberty Safeguards assessors or other types of mandatory second-opinion work.
• Old age psychiatrists see many patients in their own homes, in residential or nursing homes or in community settings, with fewer attending out-patient clinics than is the case in adult psychiatry. This will involve travelling and therefore reduces the numbers of patients that can be seen, but in doing so makes services more outreaching and patient focused.
• Old age psychiatrists, like general adult psychiatrists, can be appointed to solely in-patient, community or mixed jobs. The majority of consultant old age psychiatry posts are now appointed to either community or in-patient settings, but some will have roles in both settings. Liaison old age psychiatry can also be part of these roles however this is not viewed as ideal compared to a dedicated Consultant in Old Age Liaison.
• Old Age Psychiatrists like other psychiatrists can deliver care in non-traditional methods including remote working and hybrid working which can have its own unique challenges. Initial medical assessments should preferably be conducted face to face.
• Old Age psychiatry continues to evolve with Old Age Psychiatrists being appointed as consultants providing care in Crisis teams for older adults, Care home liaison and home treatment, working with PCNs.

• The clinical work of a community-based old age psychiatrist can be described in the categories defined under community roles earlier in the document. The support from other clinical members of the team will determine the time needed to be allocated to the separate roles.
• The balance of out-patient and home visit work within an old age psychiatry community-based post will be different to an adult psychiatry post. Fewer patients are seen within the out-patient clinic. The growth in demand for memory assessment services and early diagnosis requires dedicated senior medical time for this purpose. New patients in an out-patient clinic require a minimum of 1 h 30min for assessment, with 30 to 45 min for follow-up appointments. Acknowledging the greater focus on community-based assessments, a minimum of 1.5 h for new assessments and 1 h for follow-up assessments with additional time included to incorporate travel time is a reasonable standard. Clearly, if the geographical area covered is large, these times will need to be extended. Time should be allocated within community and out-patient sessions to allow for emergency assessments, liaison with other colleagues. For example, a full time Consultant ( 10 PAS) could expect 4 to 7 new patient referrals a week depending on whether patients are assessed at clinic or at home ( allowing for travel time depending on or/and complexity).
• The time needed for direct assessment and review may be reduced if significant parts of the assessment and management are carried out by other members of the MDT however time will need to be allocated to discuss the assessment and further management.
• Liaison with primary, secondary care old age medicine services, community services as well carers and family is an important part of old age psychiatry consultant role. This indirect patient contact will also need to allocated time in the job plan
• Job plan time needs to be allocated for mental health capacity legislation work. As with all consultant appointments, time in the job plan needs to be allocated for supervision of doctors in training. The principles for this would be similar to those within general adult psychiatry.
• Multi-professional working requires meetings to discuss patient care and individual meetings with other clinicians; 1 PA should be allocated for this in all job plans. Clinical Supervision of non-medical professionals and resident doctors should be time-tabled separately in the job plan under DCC.
• There is an increasing number of older adults presenting with Complex Emotional Needs, Eating disorders, Autism and ADHD, Substance Misuse, Personality Disorders If there are no age appropriate services available locally including dedicated old age crisis and home treatment teams then the Consultant Old Age Psychiatrist will need additional time for new assessments, review and MDT work or a smaller caseload.
• Time for the completion of necessary clinical administrative tasks from clinical work will need to be allocated in the job plan separately.
• Most jobs will need 1 programmed activity (PA) for clinical administration. Most clinicians are reporting a significant increase in clinical administrative duties, resulting from direct patient contact including recording assessments on electronic records, clinical letters to other professional, ordering and reviewing investigations, DVLA assessments etc.
• Flexibility within job planning is needed to accommodate roles depending on team structure, such as supervision of non-medical prescribing, involvement in adult protection meetings. This needs to be reflected in the expectations of the number of out-patient and community sessions undertaken.
• It is difficult to be precise about the required number of old age consultants per population served. Many factors influence the appropriate case-load for an old age consultant, such as:
• Demographics – high numbers of old people, especially aged over 80, equate to high numbers of people with dementia, depression and comorbid presentations. Support – if there is a poorly resourced multidisciplinary team this places more pressure on consultant time. In turn, this lowers the catchment population which can be managed successfully.
• Care home numbers – care homes can create heavy demand owing to capacity legislation. The use of antipsychotic drugs in care homes is high and creates demand for consultant review.
• The presence of older people’s consultation/liaison teams may reduce or increase workload for community consultants, depending on how services are structured. Services offer- ing proactive assessment in general hospitals have heavier demand than reactive services.
• A number of other factors, such as the co-location of teams and services, referral patterns from primary care, and the extent and nature of local authority services and other third sector services. Further guidance on these factors and job planning is contained in a report published by the College’s Faculty of the Psychiatry of Old Age (2015).
• All community job descriptions must include case-load analysis that should provide some information on the number of new referrals, break-down of numbers of cases by diagnosis and, where applicable, average numbers of patients on a community treatment order (CTO) over the past 1–3 years. This should be accompanied by an indicative follow-up timetable that should allow the calculation of a viable case-load range for the job. Ideally these calculations should be mapped to National or NICE or similar quality standards to ensure that patients are receiving high-quality care.
• The above principles can also be used for consultants who work in other community based posts such as memory clinic, crisis and home treatment teams etc (but may need modification depending on the post).

In-patient beds in old age psychiatry are divided into two categories, functional illness beds and beds for dementia assessment and treatment. The following applies to both single and mixed gender wards.

Beds for functional illness in elderly patients

Patients admitted to these beds are potentially the most unwell within psychiatric services. They often have complex physical comorbidity and can have comorbid symptoms suggestive of dementia. Consultants in these posts should have sufficient time within their timetable to personally review each patient at least once a week.

Ideally the consultant will be available daily to visit the ward and participate in multi-professional decision making and complex risk management, especially if the service is solely for inpatients. While this may not be possible in a mixed job, adequate time should be given for remote contact within the job plan.

Some commissioned services involve responsibility for everyone over the age of 65 transferring to older people’s services. This changes the mix of patients for whom a consultant is responsible and this needs to be reflected within job planning.

• All in-patient consultants spend a significant amount of time on mental health legislation work. Organisations must make judgements, based on previous experience, as to the amount of time this involves for each consultant. Each statutory hearing or tribunal is likely to require 1 PA in the preparation of the report and attendance at the tribunal. However, the increase in approved clinician, or responsible medical officer, work and the tendency towards longer and more complex tribunals may mean that 1 PA for in-patient consultants may not be adequate, and the job plan modified accordingly.
• Other clinical administrative tasks concerning in-patient care (e.g. unscheduled telephone calls, correspondence, checking of blood tests) require 0.5 PAs per week – this is spread throughout the week.
• In-patient consultants would expect to work alongside and support junior colleagues, year 1–3 core residents (CT1–3) and/or specialty doctors, who would be able to undertake some of the medical tasks required with appropriate supervision. However, this needs to be balanced with time required for additional clinical supervision. With the expansion in foundation training placements in psychiatry, many in-patient units provide placements for F1 and F2 doctors. These trainees require closer supervision and this needs to be factored into the consultant’s job plan.
• Some services may not have access or support from services such as Care of The Elderly, Neurology or Advanced Nurse Practitioners. If this is the case, then the job plan will need to reflect the extra time needed to manage these additional physical conditions.
• Principles of case-load analysis discussed for community psychiatrists also apply to in-patient consultants. An analysis of numbers admitted, length of stay, numbers discharged, numbers of involuntary admissions, numbers of patients lacking capacity etc. should allow calculation of a viable timetabled job plan.

FT consultant – functional illness

As with general adult psychiatry, it is likely that a whole-time in-patient consultant for functionally ill older adults can manage between 14 and 17 beds with additional support from another middle grade and /or an ST4–6 preferably with section 12 approval (or equivalent).

The consultant would expect to supervise a more junior doctor to assist in the management of the physical healthcare needs of these patients. The work relating to mental health act work and mental capacity act may vary from hospital to hospital and should be job planned accordingly.

The focus to increase care in the community for this group of patients will result in only the most complex and challenging patients being admitted to in-patient beds. The length of stay of such patients is expected to reduce and thus the amount of consultant time traditionally available for this bed base needs to be increased. In many in-patient settings most patients are initially subject to assessment under mental health legislation.

All in-patient consultants spend a significant amount of time on mental health legislation work. Organisations must make judgements, based on previous experience, as to the amount of time this involves for each consultant. Each statutory hearing or tribunal is likely to require 1 PA in the preparation of the report and attendance at the tribunal.

This work is likely to require a minimum of 1 PA per week for all in-patient consultants. However, the increase in approved clinician, or responsible medical officer work and the tendency toward longer and more complex tribunals may mean that 1 PA for in-patient consultants may not be adequate, and the job plan modified accordingly.

Other clinical administrative tasks concerning in-patient care (e.g. unscheduled telephone calls to patient’s relatives/ carers, correspondence, checking of blood tests, neuroimaging and metabolic parameters ) require 0.5 Pas per week – this is spread throughout the week.

In-patient consultants would expect to work alongside and support junior colleagues, year 1–3 core residents (CT1–3)and/or specialty doctors, who would be able to undertake some of the medical tasks required with appropriate supervision. However, this needs to be balanced with time required for additional clinical supervision. With the expansion in foundation training placements in psychiatry, many in-patient units provide placements for F1 and F2 doctors. These trainees require closer supervision and this needs to be factored into the consultant’s job plan.

Some services may not have access or support from services such as Care of The Elderly, Neurology or Advanced Nurse Practitioners. If this is the case, then the job plan will need to reflect the extra time needed to manage these additional physical conditions.

Principles of case-load analysis discussed for community psychiatrists also apply to in-patient consultants. An analysis of numbers admitted, length of stay, numbers discharged, numbers of involuntary admissions, numbers of patients lacking capacity etc. should allow calculation of a viable timetabled job plan.

FT consultant – dementia and assessment treatment

The consultant would expect to supervise a more junior doctor to assist in the management of the physical healthcare needs of these patients. The work relating to mental health act work and mental capacity act may vary from hospital to hospital and should be job planned accordingly.

Some areas where there are continuing care beds, the need for medical time will depend on the nature of admissions, but approximately 1 PA for 12 beds would be an average requirement.

The model for liaison services in old age psychiatry is variable. Where there is no designated liaison service, the CMHT often provides a consultancy service. Whichever model is commissioned, clear allocation of consultant time needs to be in place. This sessional time is in addition to the clinical commitments outlined previously.

The service design needs to be supported by non-medical liaison staff with relevant skills who will require clinical supervision and leadership from the consultant involved in the service delivery and such will need dedicated time to deliver this.

In areas where consultants provide both in-patient and community services, the principles set out for community and inpatients apply with time allocated for travel between the two. Sector based posts are likely to require a balance of PAs for both wards based and community-based work.

The population size of community patches and number of in-patients will need to be adjusted according to the number of sessions. It would not be feasible for a consultant to attend the ward each day but should be available to discuss issues that might arise with their patients. They should have flexibility within their timetable to allow this and to be attend the ward at short notice if necessary.

Consultants may be appointment to provide input for older adults as part of a crisis or home-based treatment. This can include people with functional illnesses as well people with dementia and the wider team will need to have the relevant skills to manage the full range of presentations of older people.

If the wider MDT do not possess the relevant skills then the consultant will need more time with assessment and management. Consultants contracted to posts in crisis team/home treatment for old age psychiatry only should not be expected to provide clinical input for working age adults (unless they have been appointed to provide ageless care or if the patient has dementia of early onset). The timetable will be similar to a consultant based in the community.

Principles of case-load analysis discussed for community psychiatrists also apply to allow calculation of a viable timetabled job plan.