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Faculty for Children, Young People& their Families

Clinical and applied psychologists in child and

adolescent mental health services Recommendations about numbers,

gradings and leadership

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Children and young people (USED ID314)

Children and young people

Children and young people

Children and young people

Children and young people

Children and young people

Children and young people

To develop good quality Child and Adolescent Mental Health Services (CAMHS) within constrained financial circumstances requires careful consideration be given to the mix of staff and skills within teams. In this paper, we clarify the roles that NHS trained clinical psychologists undertake, and give some indications for staffing and grading within services to ensure maximum clinical effectiveness and efficient use of resources.

The specific role of clinical psychologistsIf you are going to run a child mental health service which applies the latest scientific understandings in biology and psychology to achieving the best possible outcomes for children, you need applied scientists (clinical doctors) of both biology and psychology. The NHS therefore trains two types of doctors to specialise in mental health, psychiatric doctors and psychological doctors. Both are essential to the safe and effective delivery of clinical care, with psychiatric doctors being unique in the service in their ability to bring doctoral level biological (medical) science to the service, and psychological doctors (clinical psychologists) uniquely equipped to bring doctoral level psychological science to the service.

Clinical doctors (psychiatrists and psychologists) are best placed to oversee healthcare within each of those domains respectively, as they are trained in the broad underlying academic knowledge base, as well as in the delivery of specific interventions. This allows them to carry out the most complex assessments, and also to provide tailor-made care where there is no universally agreed specific intervention for a particular presentation, or where the normally delivered intervention is not proving successful in a particular case.

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Benefits of employing clinical psychologistsAs well as carrying out specialist assessments and interventions, one benefit of the broad theoretical and whole-lifespan training that clinical psychologists undertake is that it equips them to maximise the output of other staff via training, consultation and supervision. This can support others to deliver a range of interventions, across a range of settings, from health promotion and primary prevention through to specialist therapies.

In the context of austerity and constrained budgets, clinical psychologists both directly provide, and assist others to provide, essential core services within CAMHS, such as:

■■ Psychological assessments of complex family presentations which require cross life-span and cross theoretical speciality knowledge.

■■ Neuropsychological assessments required to comprehensively assess children who may have intellectual disabilities, autistic spectrum disorders, acquired brain injury, etc.

■■ Expert-designed interventions based on the whole knowledge base of psychology (rather than the modification of an existing therapy) for presentations where no specific therapy is indicated.

■■ Expert-designed interventions in cases where specific therapies have not proved effective.

■■ Consultation, training and supervisory capacity across specific therapeutic modalities.

■■ Doctoral-level psychological research skills to interrogate the evidence base and ensure that services remain at the cutting edge in terms of their treatment delivery.

Deciding on how many psychology professionals are requiredThere are a number of complexities to be considered when calculating how many psychology professionals are appropriate for the delivery of effective services. The seminal documents1 that have informed the debate about CAMHS staffing requirements to date have used the following model:

Epidemiology x likely attendance x intervention requirements.

In general, expected attendance is considered to be around 20 per cent, rising to 90 per cent for more severe presentations, and it is assumed that the majority of the population would remain under primary care services, with about 25 per cent of those with child mental health issues being seen by specific CAMHS.

In accordance with the above thinking, Kelvin (2005) recommended:

To provide tier 2–3 CAMH services to a population of up to 100,000 up to their 17th birthday: 2.5 medically qualified whole-time equivalent staff at consultant level; 13.5 whole-time equivalent psychologically qualified staff at a range of levels.

And:

To provide a comprehensive tier 2–3 service (including input to youth offending and substance misuse services) to a population of up to 100,000 up to their 18th birthday: 3.9 whole-time equivalent medically qualified staff at consultant level; 21.6 whole-time equivalent psychologically qualified staff at a range of levels.

1 Davy, R., & Littlewood, S. (1996). You pays your money and you takes your choice. Helping purchasers to commission an appropriate CAMHS. Psychiatric Bulletin, 20, 272–274.

Goodman, R. (1998). Child and Adolescent Mental Health Services: Reasoned advice to commissionersand providers. Maudsley Discussion Paper No 4. Institute of Psychiatry, De Crespigny Park, London.

Kelvin, R.G. (2005). Capacity of Tier 2/3 CAMHS and Service Specification: A model to enable evidence-based service development. Child and Adolescent Mental Health, 10(2), 63–73.

Royal College of Psychiatrists (2013). Building and sustaining specialist CAMHS. November. Royal College of Psychiatrists Report CR182.

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Deciding on the skill mix of the psychologically qualified staff within the serviceWhilst clinical psychologists are able to deliver across the range of psychological interventions, we are not recommending that all the psychological staff within a service need to be doctoral level psychologists. Specialist psychological therapists (such as systemic psychotherapists, CBT therapists, etc.) and nurses with specific training in psychological therapies are all able to provide high quality therapeutic services, and it makes sense to plan a service making use of this range of psychologically qualified staff. We would recommend specifically making use of the expertise of clinical psychologists where:

■■ a neuropsychological or cognitive assessment is needed (such as in the case of children with intellectual difficulties, those with autism spectrum disorders or physical conditions which are affecting their psychological functioning);

■■ there is significant distress / impairment in functioning, but a diagnosable disorder is not identifiable, and therefore there is no obvious specific therapy to be offered;

■■ children and families have not responded well to the specific interventions recommended in national guidelines and therefore need a specially tailored approach.

Based on CAMHS data2 for cases that fall into one of these three criteria, we would recommend that clinical psychologists make up at least 50 per cent (i.e. 10.5 whole time equivalent members of staff) of the psychological workforce within CAMHS. These should be at a mixture of grades, with the largest proportion being Bands 7 or 8a, overseen by a smaller number of 8bs (dependent on size of the team) and overall leadership being with a Consultant (band 8c or d) Psychologist. In addition, the capacity of psychological establishments is increased considerably (as well as fulfilling the

2 Child & Adolescent Mental Health (CAMHS) (2013). Joint Strategic Needs Assessment, March.

NHS requirement for training) if it makes use of psychologists currently in NHS training who are available throughout the year on rotation (in a similar way to junior doctors).

Assistant psychologists are an additional way to both support efficient delivery by qualified psychologists and to support ongoing development of NHS capacity, and again are recommended in terms of delivering on NHS requirements to support training and succession planning.

Specifically, we recommend multiples of a structure of four basic grade (band 7) clinical psychologists, for every two principal clinical psychologists (bands 8a–8b), overseen by one consultant clinical psychologist (band 8c), with trainee psychologists attached to all band 8 and higher psychologists (these are supplied via central training and therefore do not represent a direct cost to the service), and one assistant psychologist. The remainder of the staff should be specialist therapists and nurses with relevant skills and experience.

This mix of staff is not only financially sound, but also ensures that there are senior consultants in psychology as well as psychiatry to engage in clinical leadership, management and service development activities, and also that there is a continued source of appropriately experienced candidates for training.

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What does good look like for applied psychological participation in CAMHS teams?In summary, the main recommendations are:

■■ There is joint leadership of CAMH services by doctors of psychiatry and psychology to ensure safe and effective delivery of both medical and psychological interventions.

■■ To meet the needs for complex psychological assessments and interventions, there is a minimum of 10.5 WTE qualified clinical psychologists per 100,000 total population.

■■ To ensure best value and best matched leadership knowledge, there is a mix of levels of psychiatric, psychological, specialist therapist and nursing staff.

■■ To maximise capacity and continuity of service, trainee and assistant psychologist posts are embedded in the service structure.

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This leaflet summarises a chapter in What good looks like in psychological services for children, young people and their families.

Hard copies can be requested for free from Helen Barnett, British Psychological Society: Helen.Barnett@bps.org.uk

Electronic copies can be downloaded for free from: http://shop.bps.org.uk/publications/child-and-family-clinical-psychology-review-no-3-summer-2015.html or by scanning the code below.

Faculty for Children, Young People& their Families

The Child & Family ClinicalPsychology Review

No 3 Summer 2015

What good looks like inpsychological services forchildren, young people

and their families

ISSN: 2052-0956

If you would like to discuss any of the information in this leaflet further, please contact: dcpchildlead@bps.org.uk