Guidelines on Activity for Clinical PsychologistsRelevant factors and the function and utility of job plans

If you have problems reading this document and would like it in adifferent format, please contact us with your specific requirements.Tel: 0116 252 9523; E-mail: [email protected]. The British Psychological Society 2012The British Psychological SocietySt Andrews House, 48 Princess Road East, Leicester LE1 7DR, UKTelephone 0116 254 9568 Facsimile 0116 247 0787E-mail [email protected] Website by Royal Charter Registered Charity No 229642

ContentsRecommendations .2Summary Statement .31. Introduction.42. Clarifying some aspects of the work .52.1 Terminology2.2 Length of client contacts2.3 Non face-to-face aspects of client work2.4 Travel time2.5 Supervision and CPD2.6 Part-time workers and those in split posts3. The value and role of job plans .83.1 Working out a job plan3.2 Example job plan for a Band 8a Clinical Psychologist within a communitymental health team for older adults3.3 Example job plan for a Band 8b Clinical Psychologist in a service for adultsof working age in secondary mental health3.4 Example job plan for a Band 8c or 8d Clinical Psychologist working in a child,adolescent and family service in secondary care3.5 Example job plan for a Band 9 Clinical Psychologist4. Targets for client activity .145. Balance of direct clinical to indirect clinical activity or non client related activity .146. Group work versus individual work .147. Caseload .158. Additional factors .16(a) Generic team/service activity/duty(b) Care co-ordination roles(c) Waiting times and waiting lists(d) Trainees9. Disagreements about clinical activity.18References .19Appendix .20Contributors .23Guidelines on Activity for Clinical Psychologists1

Recommendations1. all clinical psychologists have a job plan that is reviewed at least annually andagreed jointly with the post holder, their manager and with input from a more seniorclinical psychologist.That any job plan addresses and incorporates the full range of work that will beundertaken, including team meetings and indirect work such as supervision andsupport to others, professional activities such as CPD and personal supervision, andany additional responsibilities.That ‘proxy contacts’ are accepted where there is significant work through family,carers and other staff members and adopted as part of activity recording.That referrals are addressed by the whole team or jointly with the team manager inorder to ensure appropriate prioritisation and to assist the direction of thepsychologists use of time.That trainees’ caseloads be included in that of the supervisor and that thesupervisors’ clinical activity be reduced by the equivalent supervision time.DCP Professional Standards Unit

Summary statementThe Division of Clinical Psychology does not have a formal policy on caseload numbers ortime distribution between the various spheres of professional activity. The principal reasonfor this is that all posts are different in their composition, objectives and managementarrangements, and to provide benchmark recommendations would restrict post holdersability and capacity to develop posts in line with the changing needs of services.However, the Division of Clinical Psychology does advise members to ensure that allprofessional aspects of a post receive attention and are fully represented in the postholder’s job description and personal development plan. Consequently, giving andreceiving supervision, providing consultancy and teaching, and engaging in service relatedresearch should be adequately represented in weekly or monthly job plans, as well as coreclinical activities and administrative tasks. There may also be a need to factor in travel timefor some posts which serve a large geographical area or where there are a large number ofvisits to other sites to see clients.Any local agreements on the percentage of time spent in each activity should be reviewedat least annually as part of the local appraisal process and be informed by service objectivesand the individual’s development needs and competencies.This document:nclarifies some aspect of the practise of clinical psychology;noutlines the range of areas of work that will come under the remit of a clinicalpsychologist;nmakes recommendations about how a local arrangement might be best developed;nmay help in finding innovative solutions to provide a cost effective, well focused andquality service.It also provides examples of job plans for different grades, although, given the range ofspecialist areas of work and variation in roles, these should be viewed as illustrative only.Guidelines on Activity for Clinical Psychologists3

1. IntroductionThe purpose of this document is to provide information and guidance to underpindiscussions about the clinical activity of clinical psychologists.It is intended to outline for clinical psychologists standards and expectations for activityand to assist managers, team members and other colleagues to understand the nature andscope of clinical psychologists’ work. The document aims to:nnnndescribe the type and range of work conducted by clinical psychologists;explain some of the broader aspects of clinical psychologists’ work that affectclinical activity;clarify some of the issues that may occur when setting targets for clinical activity;set out an effective process for reaching working arrangements in order to ensurethat clinical services are provided in the appropriate way within a clinical context.In addition it may also:nDemonstrate to managers and commissioners who are not familiar with the work thatpsychologists do, the range of work/activity that can be expected from a clinicalpsychologist at a specific grade and why, say, a clinical psychologist in a Band 8c or 8dpost might take on less direct clinical work than someone in a Band 7 or 8a position.It will help to orientate them to the skills and competencies a psychologist brings toan organisation at different grades.nHelp managers to understand more clearly the range of work psychologists do andwhy they do what they do, and help begin the dialogue about choices about whatthey receive.nBe used as an important ‘support tool’ for determining what might be expected froma psychology service.It needs to be stressed that the range and type of work of clinical psychologists is verywide, spanning the more intensive high volume activity that might occur within anIAPT service within primary care to a specialist neuropsychology assessment servicewhere the emphasis will be on thorough and time consuming assessments for a smallnumber of individuals.This document should be read in conjunction with the Core Purpose and Philosophy of theProfession (BPS, 2011a), Good Practice Guidelines for Clinical Psychology Services (BPS, 2011b),Guidelines on CPD for Clinical Psychologists (BPS, 2011c), New Ways of Working for ClinicalPsychologists (BPS, 2007) and the Leadership Development Framework (2010). IndividualFaculties, areas such as The Faculty for Children, Young People & Their Families and TheFaculty for Learning Disabilities, have produced more specific guidance on corecompetencies. The NICE guidelines give specific recommendations for psychologicalinterventions for certain problem areas (although they do not specify the details).This guidance addresses:nclinical contacts;nbalance of direct clinical to non-client related activity;ncaseload;ncare co-ordination roles.4DCP Professional Standards Unit

2. Clarifying some aspects of the work2.1 TerminologyA full-time clinical psychologist will work 37.5 hours per week under the NHS Agenda forChange. For people working part-time, this would apply on a pro rata basis.When psychologists chunk their clinical time they tend to talk in ‘sessions’, each of half aday, and thus it is common to talk about doing ‘eight sessions of clinical work’ per week,rather than, as with professions such as physiotherapy, individual client contacts. This canbe confusing and care should be taken to avoid ambiguity and misunderstanding.2.2 Length of client contactsThese vary widely and need to be understood in terms of the type of work and the purposeof the intervention and thus may need local agreement. Electronic health records recordeach contact for face-to-face activity for individuals (including carers); they may notincorporate in data reports the length of each contact.For instance, at one extreme a developmental assessment for a child with suspected autismmay require them to be seen for one and a half to two hours at a time while a range of testsare administered, or a neuropsychological assessment for a person after a stroke mayrequire three hours. At the other extreme, a brief consultation within a diabetesmultidisciplinary clinic might be 20 minutes. These would both be recorded as one contacton many systems even though the duration is markedly different.The most usual duration of an intervention is one hour (therapeutic hours – 50 minutes ofdirect client contact and 10 minutes for preparation and/or recording). Follow-up sessionsmight be 30 minutes or may still be the full hour.2.3 Non face-to-face aspects of client workRecommendation: That ‘proxy contacts’ are accepted where there is significant work through family,carers and other staff members, and adopted as part of activity recordingIn some areas of work there may be considerable preparation time where the psychologist carriesout consultation with colleagues within the clinical team and may see the individual client for arelatively brief face-to-face intervention. This is not well reflected in electronic health recordswhere the recording is usually only of face to face contact or carer contact. In many services theintervention might be wholly indirect and carried out through other staff. Examples of this mightbe an assessment for a child with development delay (where the psychologist would talk withschool staff, colleagues in medical services and other therapists) or when working to reducechallenging behaviour within a care setting for someone with learning disabilities or dementia.The concept of proxy contacts is a useful way of reframing indirect work that is an agreedconcept in some areas of work. Proxy contacts are commonly used in children’s services, buthave also been used in Learning Disability services, and a case can be made for them being usedmore in adult and older adult services too. It must be understood that there is a distinctionbetween proxy contacts and people who assist in psychologists’ work by providing information(e.g. as part of an assessment or in reviewing an intervention). Proxy contacts do what a clinicalGuidelines on Activity for Clinical Psychologists5

psychologist might do, but at the request and under the direction of the psychologist. The idea isthat one is assessing, intervening or treating the individual by working through someone else(e.g. a family member or paid carer in recording behavioural interventions). It could include thedirection under supervision of other staff delivering basic level psychological interventions (e.g.supporting a community nurse in helping a client with managing anxiety or anger).In addition, where the work is in highly complex areas there could be a considerablecommitment to reading about technical aspects of the work and writing individualisedformulations and detailed care plans for the individual. An example might be anassessment within a specialist trauma service for a person without English as a firstlanguage from a country where the cultural aspects might be a crucial factor toincorporate and necessitate considerable research. This might include working through aninterpreter, which requires significantly more time (Guidelines on Working with Interpreters;BPS, 2011). Again, this time will not be reflected in day-to-day activity recording. It may belegitimate to collect this information through an audit to inform managers and supervisorsof the range of activity undertaken.In terms of service planning, there are several method of calculating the time requirements ofthe various elements of a psychologist’s job plan (Newton, 2011; Huey, 2012 – y for clinical psychologists - guidelines - accompanyingdocuments This is useful for purposes such as agreeing workloads or targets, prioritisingtasks, service planning, and informing managers or commissioners about the likely productivityof a service that has identified tasks and a set staff group. This method allows estimation of timerequirements for tasks that range from the simple to the complex. Complex tasks – such asworking with a person with dementia and challenging behaviour in a residential setting – canbe broken down into smaller elements to improve the accuracy of estimation.2.4 Travel timeThis issue is obviously not specific to clinical psychology but, with the move towards morecommunity working, travel time can be significant.Where clinical psychologists work on different sites within a working day, this may impacton their use of time.In addition, where there is a high amount of home visits or visits to see clients on particularsites (such as a community resource centre), this may add significantly to the time taken tocomplete the clinical contact, adding between 50 and 100 per cent extra time (or even 200per cent in rural areas) to the actual clinical intervention. Local agreement should besought to recognise the implications for levels of clinical activity.Clinicians and services should optimise travel arrangements wherever possible.2.5 Supervision and CPDAll clinical psychologists are required to undertake supervision and CPD – this is identified bythe Department of Health (DoH, 1998), the Society (BPS, 2008) and the Health ProfessionsCouncil (HPC, 2008, 2009a, 2009b). The HPC requires time spent on CPD to be recordedand this could be audited in the future. The Society’s Division of Clinical Psychology (DCP)provides guidance on supervision (BPS, 2006 and in development) and CPD (BPS, 2011).6DCP Professional Standards Unit

Supervision will take several forms: managerial supervision is provided by the line manager,who may not be a clinical psychologist; clinical supervision addresses clinical competenciesand is provided by someone with expertise within the model of working (who may not be aclinical psychologist). There will also be professional supervision received from a moresenior clinical psychologist.The DCP recommends that a full-time worker should have a minimum of 10 days per yearstudy leave, pro rata for part time workers (BPS, 2011c).For CPD, there are a range of ways in which this may be addressed. Within some posts CPDis provided as a core part of the job (such as for an IAPT High Intensity Worker); othertimes there may be a formally allocated amount of time within the job plan for CPD to beundertaken. This latter arrangement is more common in junior grades, but would beexpected for all staff.Sometimes the psychologist is, with agreement from all, undertaking a course requiring asubstantial time commitment. For instance, a course might require attendance one day per weekfor academic teaching with a further half day on supervised clinical work. Where this is agreed tocome out of the normal working week, this time would be identified within the job plan.2.6 Part-time workers and those in split postsA high proportion of the clinical psychology workforce work part-time and there are alsopeople working a few sessions a week. Some people may work in a split post where theyhave two different managers and relate to two different services. It is particularly importantin these situations to provide a job plan, for two reasons:Firstly, all the areas identified within a job plan need to be addressed in discussions aboutworkload, etc. – a person working four sessions/two days per week will still requiresupervision and access to CPD rather than being viewed as a resource for two days of directclinical provision. Even the need to free up time to provide some staff training tocolleagues within the service would need to have time identified for it, without puttingundue pressure on the staff member.Secondly, a psychologist working part-time in a service may be faced with dilemmas aboutthe use of their time that it would be better to share with managers and supervisors andagree how to deal with them. For instance someone working 0.5 wte within a Child &Adolescence Tier 3 service might be unclear whether they should regularly attend thewhole of the weekly referral allocation meeting, taking up two hours of their time, orattend less frequently or attend for part of the time or as requested by the team manager.Case StudyMarie worked two days a week in a pain clinic where her time was fully committed inteam meetings, and individual and group client work. This work was also at a distancefrom other psychologists for supervision and CPD. It was agreed between Marie, hermanager and psychologist supervisor that she would have one session per month toinclude supervision and attendance at the psychology CPD event. No client work wasbooked in for this session.Guidelines on Activity for Clinical Psychologists7

3. The value and role of job plansRecommendation: That all clinical psychologists have a job plan that is reviewed at leastannually and agreed jointly with the post holder and their manager with input from a moresenior clinical psychologist.The most effective means to clarify the clinical activity is to work it out as part of a job plan(Department of Health, 2004). This could be best done between the individual, the servicemanager and the professional supervisor. Sometimes the staff member provides a record ofall activity over a time period (say a month) to inform the meeting. Trafford HealthcareNHS Trust (Huey, 2010) has a detailed system for describing the range of activitiesundertaken by psychologists and Greater Manchester West Mental Health NHSFoundation Trust has a system for recording work activity in preparation for adevelopmental review (Greater Manchester, 2010 – l-psychologists .cfm).A job plan should be devised after reference to:nthe job description (describing the range of clinical duties to be performed);nthe person specification for the post (identifying the level of competency expected).And from the development review:nthe individual’s objectives (these would outline the priorities set from theorganisation for use of time);ntheir Personal Development Plan, which should identify training needs and plans forthe individual.3.1 Working out a job planRecommendation: That any job plan addresses and incorporated the full range of work that will beundertaken, including team meeting and indirect work such as supervision and support to others,professional activities such as CPD and personal supervision, and any additional responsibilities.Consideration would be given to time required for the following eight areas of work(different systems might address these differently or use a different method ofcategorisation, but all areas should potentially be included).Clinical1.2.3.8Attendance at regular meetings such as team/service clinical and business meetings.Where the person is in split posts or covers several teams, they may not be able toattend each one or may only attend part, so some indication of frequency/attendancewould be useful.Activity relevant to direct face-to-face work with individuals such as assessment andinterventions. This area should also include clinical administrative time, completingelectronic health records, report writing, etc., and proxy contacts (seerecommendation).Other direct clinical activity such as: running groups or providing consultation to (orsupervision with) other staff about their clients; and face-to-face work with carers,parents, partner, etc. (for which there will be identified service users).DCP Professional Standards Unit of trainee psychologists.Non-clinical support activity such as running a reflective practice group for ward staff,supervising other members of the team, providing some local team training, carryingout an audit, doing duty, and clinical supervision of psychology staff.Additional responsibilities – activities and roles related to professional supervisionand line management, service delivery, governance and service development wherethis is formally agreed with managers. Clinical and professional supervision ofqualified psychology staff should come under this area, as could work in staff trainingand development, research and development, and audit or outcome measurement(this section could be broken into different headings where this is a majorcomponent of work).Time identified for own clinical, management and professional supervision.Allocated regular time for CPD activity.There are a range of approaches to structuring work plans and in some organisations thismay be done centrally, so this structure needs to be seen as providing an illustrative way ofmeeting the needs of clinical psychologists.One important distinction is how much is ‘loaded’ onto clinical activity and how much isidentified as ‘non-clinical’. There are pros and cons to either approach. Some of this mayrelate to how the service operates or how activity is commissioned (e.g. costed by numberof contacts or by case).It can be argued that, for instance, supervision of colleagues and trainees is a form ofclinical activity in that it impacts directly onto client care. On the other hand, it could bethat it is valuable to reflect accurately that this can be a substantial and cost effective use oftime for a clinical psychologist and thus should be identified separately.In addition, there may be an issue related to pension entitlement for some – for example,for those employed under special conditions (e.g. Mental Health Officer status) – whowould need to be careful that their proportion of clinical activity does not drop below acertain level if they wish to retain this status.In some systems where the individual staff member has a specified management orprofessional role, these sessions are taken out of the job planning in relation to theproportion of client work. So, for instance, where the psychologist is a full-time employee,but within this works two days a week in a research position or in a training role within theservice, their job plan should be based on being available for three days or 0.6 wte.The Royal College of Psychiatrists’ (Department of Health, 2010) approach to jobplanning is widely recommended and utilised.The following examples separate out the eight components to illustrate the range of workcarried out and the proportion of time that may apply for each activity. The ratio of clinicalto non-clinical activity is based on a narrower definition of clinical.These examples are all on the assumption of full-time worker (1.0 wte) and are forillustrative purposes only, although a recent survey based on these categories did validatesome aspects of the approach (Shenoy & de Villiers, 2011).Guidelines on Activity for Clinical Psychologists9

3.2 Example job plan for a Band 8a Clinical Psychologist within acommunity mental health team for older adultsFor a full-time Band 8a Clinical Psychologist the breakdown of time shown belowwould be common.This reflects a 60:40 ratio of direct clinical to non-clinical activity.Category of activityTime allocationComments1. Attendance at team meeting 1 session1 session per week(plus admin time, includingpreparation of materials)2. Direct face-to-face work with 5 sessionsindividuals (including newassessment and treatment cases)1 session Memory Clinic3. Other direct clinical activity0.5 sessionRunning Relapse PreventionGroup for depression(6–8 attendees)4. Supervision of traineepsychologists0.5 sessionTrainees carry out client workand support the work of thequalified staff member5. Non-direct clinical support1 sessionProviding supervision toassistant psychologists andcommunity psychiatric nurses;Auditing team referrals againstNICE guidance6. Additional responsibilitiesAd hocOccasional attendanceat meetings7. Own supervision0.5 sessionsClinical and managerialsupervision8. CPD activity1 sessionAdvanced CBT training10DCP Professional Standards Unit

3.3 Example job plan for a Band 8b Clinical Psychologist in a service for adults of working age in secondary mental healthAs mentioned earlier, the activities of a clinical psychologist on any particular grade willdepend on the actual job and the nature of the duties. However, in general, the moresenior the grade the higher the ratio of non-direct to direct clinical activity.Thus a Grade 8b Clinical Psychologist might have a job plan as shown below.This reflects a 50:50 ratio of direct clinical to non clinical activity.Category of activityTime allocationComments1. Attendance at team meeting. 1 session1 afternoon per weekplus admin time2. Direct face-to-face work3 sessionswith individuals (including newassessment and treatment cases)1 session working in aninpatient ward providing stafftraining and consultationabout individual service users;1 session supervisingcolleagues within the team andproviding clinical supervisionfor clinical psychologists;1 session complexcases ‘clinic’3. Other direct clinical activity0.5 sessionRunning a self-managementgroup for bipolar clients4. Supervision of traineepsychologists (2)1 sessionTrainees carry out client workand support the work of thequalified staff member5. Non-direct clinical support2 sessionsSupervising colleagues in team.Providing training to staff onan in-patient ward;Offering consultation withinthe ward;Clinical supervision of clinicalpsychologists6. Additional responsibilities1.75 sessionsProviding professionalsupervision and consultation to7/ 8a psychologists inthe service;Overseeing referral allocations;Chairing local audit group;Attending service meetings7. Own supervision0.25 sessionClinical and managerialsupervision8. CPD activityNo designated timeAgreed ad hocGuidelines on Activity for Clinical Psychologists11

3.4 Example job plan for a Band 8c or 8d Clinical Psychologist in achild, adolescent and family service in secondary careA Band 8c/8d Clinical Psychologist might have the job plan shown below.This reflects a 40:60 ratio of clinical to non clinical activity.Category of activityTime allocationComments1. Organising and attendingclinical team meetings1 sessionChairing clinical team meetings2. Direct face-to-face workwith individuals2 sessionsIncludes new assessment andtreatment cases (one sessionneurodevelopmentalassessment meeting)3. Other direct clinical activity1 sessionFortnightly consultationsessions with home visitors;Overseeing family therapy clinic;Ad hoc consultations withother teams4. Supervision of traineepsychologists (2)0.5 sessionTrainees carry out clinical workand support the work of thequalified staff member5. Non direct clinical support2 sessionsClinical psychologyprofessional supervisionof grade 8b clinicalpsychologists and professionaldevelopment work6. Additional responsibilities3 sessions1 session service developmentwork (autism development);1 day per month staff training,plus preparation;Attendance at servicemeetings, including chairingClinical Governance meetings7. Own supervision0.5 sessionOwn clinical and managerialsupervision plusadministrative time8. CPD activityNone allocatedAddressed as part of 612DCP Professional Standards Unit

3.5 Example job plan for a Band 9 Clinical PsychologistA Band 9 Clinical Psychologist might have the following job plan. They would oftenmaintain a small area of clinical work.This reflects a 10:90 ratio of clinical to non-clinical activity.Category of activityTime allocationComments1. Organising and attendingteam meetings0.5 sessionChairing psychologymanagement meetings plusassociated admin2. Direct face to face workwith individuals1 sessionIncludes new assessment andtreatment cases3. Non-direct clinical support3 sessionsClinical Psychologyprofessional supervision of 8dsand psychology professionaldevelopment work4. Additional responsibilities5 sessionsAttendance at TrustExecutive meetings;Chairs Trust PsychologicalTherapies committee;2 sessions servicedevelopment work5. Own supervision0.5 sessionOwn clinical and managerialsupervision plusadministrative time6. CPD activityNone allocatedGuidelines on Activity for Clinical Psychologists13

4. Targets for client activityThere are various ways of measuring clinic

3.3 Example job plan for a Band 8b Clinical Psychologist in a service for adults of working age in secondary mental health 3.4 Example job plan for a Band 8c or 8d Clinical Psychologist working in a child, adolescent and family service in secondary care 3