A Guide to Commissioning Paediatric Clinical
Psychology Services in the UK
Paediatric Psychology Network Briefing Paper
September 2008
1
Contents
1. Introduction
4
2. What is Paediatric Clinical Psychology?
4
3. What training and qualifications do paediatric
clinical psychologists have?
6
4. What do paediatric clinical psychologists do?
8
5. How are paediatric clinical psychology services
organised?
12
6. What evidence is there that paediatric clinical
psychologists are effective?
16
7. Summary and Conclusions
18
8. References
19
Appendix – Examples of bids for paediatric
clinical psychology posts
2
22
ACKNOWLEDGEMENTS
This document was written and produced by the Paediatric Psychology
Network (PPN). The lead authors were Melinda Edwards and Penny
Titman and we would like to acknowledge and thank the following:
The PPN committee, Diane Melvin, Alisdair Duff, Clarissa Martin, Judith
Houghton, Annie Mercer, Mandy Byron, Daniela Hearst, Sara O’Curry.
3
PROVISON OF PAEDIATRIC
CLINICAL PSYCHOLOGY SERVICES
1. INTRODUCTION
This briefing paper provides a description of the role of a clinical psychologist
working in paediatrics hereafter referred to as a ‘paediatric clinical
psychologist’ and an overview of current paediatric clinical psychology
services across the UK. It describes the context in which they have developed
and the different organisational and management systems in which current
services operate. The paper looks at the evidence base for psychological
interventions in paediatric work, including the value added by these
interventions and services. The aim of the document is to provide a guideline
for psychologists developing such services, professional colleagues who use
or wish to lobby for such services, trust boards and commissioners.
2. WHAT IS PAEDIATRIC CLINICAL PSYCHOLOGY?
Paediatric clinical psychology is a well established area of clinical psychology
for children and young people with medical conditions and physical health
needs. It has much in common with the field of clinical health psychology
which has developed for adults and uses many of the same psychological
theories, models and research evidence base (BPS, 2007a). In addition, it
also draws on those areas of applied psychology (e.g. developmental and
systemic) that are relevant to the particular needs of children, young people
and their families, as well as the healthcare system providing services for
them.
Between 10 - 30% of children are affected in some way by chronic illness or
physical health problems (Eiser, 1995). These conditions often have
consequences for the emotional and social development of the young person.
They also affect families and others involved in the child’s care. Whilst many
children and families can be very resilient and cope well with the demands of
a physical illness, children with a chronic illness are known to be at increased
risk of developing psychological problems when compared to healthy children,
with estimates of psychological difficulty ranging from 10% to 37%
(Glazebrook et al, 2003, Meltzer et al, 2000, Kush & Campo, 1998).
4
Recent government guidelines on the development of services for children
with physical health problems, for example the National Service Framework
for Children in Hospital (DoH, 2004: Standard 6) recognise the importance of
psychological input for children with chronic illness or disability:
“Much can be done to help children and young people with long term
conditions experience an ordinary life. A key element of this support
should be good mental health input to maximise emotional well-being
and prevent or minimise problems.”
And standard 7 states that:
“Attention to the mental health of the child, young person and their
family should be an integral part of the children’s service, and not an
afterthought…It is therefore essential for a hospital with a children’s
service to ensure that staff have an understanding of how to assess and
address the emotional well-being of children”.
In “Making Every Young Person with Diabetes Matter” (DOH, 2005), the
report notes:
“Routine psychological support should be part of normal provision,
rather than restricted to crisis management… services should consider
the impact on families of diagnosis and adapting to life with diabetes
and (staff) should be able to refer directly to specialist psychology that
form part of the team”
The importance of psychological input as part of a comprehensive medical
treatment plan is also included in some of the National Institute for Clinical
Effectiveness (NICE) guidelines, for example the guidelines for diabetes
(NICE, 2004). These emphasise the importance of psychological aspects of
care and recommended that routine psychological assessment should be
included, in order to evaluate the effects of persistent hypoglycaemia and
recurrent diabetic ketoacidosis on cognitive functioning.
These documents recommend that psychological services should be
considered as an integral part of children’s medical health care. This is
because it is recognised that psychological input can have a direct impact on
health outcomes by addressing problems such as adherence to treatment, as
well as reducing psychological distress. Psychological interventions can often
lead to a shorter stay in hospital and fewer medical appointments. In addition,
addressing the child’s and family’s emotional needs alongside their physical
health needs helps increase satisfaction with care.
5
3. WHAT TRAINING AND QUALIFICATIONS DO PAEDIATRIC CLINICAL
PSYCHOLOGISTS HAVE?
Clinical child psychology is the foundation for developing skills and expertise
in the field of paediatric clinical psychology (Spirito et al, 2003). The vast
majority of psychologists working in paediatric settings are clinical
psychologists, with a very few health, academic and counselling
psychologists.
Paediatric clinical psychologists have an extended training (a minimum of 7
years). They have an undergraduate degree in psychology (3 years) and will
have undertaken relevant experience as an assistant psychologist (typically 13 years) before being selected for post graduate training to doctoral level in
applied clinical psychology (3 years). Their undergraduate psychology degree
will have provided theoretical knowledge in psychological models and
research methodologies based on an understanding of normal development.
During postgraduate (doctoral level) training they will have gained clinical
experience of working in a variety of interdisciplinary settings with a range of
different patient groups and presenting problems, including working with
children, adults and people with learning difficulties. The psychologist will
have learned to apply evidence based practice across the life span, to be
proficient in cognitive and neuropsychological assessment and to be able to
use a variety of therapeutic techniques at an individual, group and systemic
level. They will also have had extensive training in research methodology and
will have completed a substantial research thesis.
This comprehensive training ensures paediatric clinical psychologists have
the necessary skills to work with complex psychological difficulties within multi
cultural contexts and draw on a range of evidence based techniques. The
report “Understanding ‘customer’ needs of clinical psychology services”,
prepared for the Division of Clinical Psychology, BPS, surveyed
commissioners, managers and clinicians and concluded that the unique
contribution and skills of clinical psychologists were their broad knowledge
base, range of approaches/ treatment modalities, skills in supervision, dealing
with complex presentations and ability to work with teams, supporting service
and organisational developments (Cate, 2007)
After qualification, clinical psychologists working in paediatrics are required to
undertake Continuing Professional Development (CPD) in order to continue to
update their knowledge and skills base, and may have undertaken further
training in specialist therapeutic techniques (e.g. family therapy) or areas of
expertise (e.g. neuropsychology). The Paediatric Psychology Network (PPN),
a network of the Faculty of Children and Young People within the British
Psychological Society (BPS) organise a national annual study day
contributing to the CPD of psychologists through a series of lectures and
networking opportunities with national and international experts in this field.
6
Most psychology services will provide regular placements to doctoral clinical
psychology training courses. This will involve 6 or 12 month placements, with
trainees undertaking supervised clinical work for 6 sessions per week. These
posts are funded by regional training centres.
Some paediatric clinical psychology departments also employ assistant
psychologists who have completed an undergraduate psychology degree.
Assistant psychologists work under close supervision and are able to support
the work of the paediatric clinical psychologists, for example by carrying out
some structured assessments and developing research protocols.
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4. WHAT DO PAEDIATRIC CLINICAL PSYCHOLOGISTS DO?
Paediatric clinical psychologists work with children and young people with a
medical illness and/or physical symptoms, their families and/or carers,
including staff. They aim to reduce distress, promote optimal development,
improve psychological well being and improve health outcomes for these
young people and their carers. In order to achieve these goals, paediatric
clinical psychologists work at several different levels:

Direct clinical work with children, young people and their families
referred because of identified concerns or those who are considered at
risk of developing difficulties

Consultation and joint work with other members of the multi-disciplinary
health care team involved in the child’s care

Conducting audit, research studies and evaluation

Participating at a strategic, service or policy level within the wider
system to improve care for children
4.1 Direct work with the child / young person and his or her family
Paediatric clinical psychologists offer assessment and therapeutic work for
children and families affected by physical illness problems. Some examples of
these types of work include:

Promoting adjustment and maximizing quality of life for children with
chronic medical conditions

Facilitating understanding and adaptation to the challenges of the
child’s illness and treatment regime

Assessment of psychological difficulties such as anxiety, depression,
body image issues, and challenging behaviour. These difficulties may
develop as a result of, or be exacerbated by, the child or young
person’s medical condition and associated treatment demands

Formulation of an appropriate psychological treatment plan drawing on
a variety of theoretical models and evidence based practice

Preparation for invasive or distressing procedures

Symptom management techniques e.g. pain management techniques

Promoting adherence to medical and allied medical treatment
8

Trauma work and bereavement support, including working with siblings
and other family members

Psychological and/or developmental assessments (psychometric tests,
standardised assessments and individually designed assessments and
interviews)

Preparation and support for adolescent populations in the transition
process to adult services as part of transitional care programmes

Group work with children, young people or families e.g.
psychoeducational workshops, support groups and user feedback
groups

Identification of co-morbid mental health needs which may require
referral on to specialist Child and Adolescent Mental Health (CAMHS)
services and risk assessment e.g. of self harm

Proactive work with children and their family based on an agreed
protocol e.g. for children undergoing organ or bone marrow transplant

Preparation and support around reintegration into school and home
following treatment and/or prolonged hospital admission
4.2 Consultation and joint work
One of the advantages of the psychologist working as an integral part of the
medical team is that this reduces the barriers between physical and
psychological models of care and facilitates communication between team
members. This helps to improve access to psychology services for children
and families compared to having to refer outside of the health service to
community child mental health services such as local CAMHS. Paediatric
clinical psychologists work alongside the rest of the health care team in order
to promote psychologically informed work by other members of the
multidisciplinary team and therefore provide psychological input to a wider
range of children and families. This can include consultation in multiprofessional ward rounds and psychosocial meetings, where the
psychological needs of the child/family can be considered in conjunction with
their medical needs. It may involve joint clinics and appointments with other
professionals. It may also involve development of programmes undertaken
with or by other staff (e.g. preparation for surgery, transition programmes).
All clinical psychologists have training and experience in supervision, and can
support the work of other members of the multi disciplinary team by providing
case supervision of psychologically based work. They are also able to provide
training for other members of the team to enable them to take on some work
9
which may be described as “low intensity” interventions (BPS, 2007b), for
example managing procedural fear and distress and protocol based
assessments. This enables more children and families to have access to
psychological interventions, and is a cost effective way of delivering
psychological care and making optimal use of psychology skills.
The psychologist is often also used as a resource to facilitate team
development and provide staff support within the clinical specialty team, for
example facilitating support groups or providing support on an individual level.
The aim of this work is to help manage and reduce staff stress but also to
promote effective communication and teamwork amongst colleagues.
Paediatric clinical psychologists can also be a valuable resource for
community and education services around the child, providing support,
consultation and training around psychosocial aspects of care for
professionals and voluntary sector staff.
4.3 Audit, training and research
Paediatric clinical psychologists have extensive experience of designing and
carrying out research as part of their doctoral training. They are able to
undertake, support and/or supervise both uni-professional and multiprofessional audit and research work. The psychologist may be directly
involved in multidisciplinary research programmes (e.g. assessing long term
impact of chronic health problems). Psychologists are well placed to advise
medical teams on the use of good quality patient reported outcome measures
as a primary outcome measure in medial research, as well as leading in the
development of new robust illness-specific measures.
Paediatric clinical psychologists provide teaching and training to other
professional groups, as well as within psychology. For example, paediatric
clinical psychologists contribute to the “Child in Mind” training scheme run by
the Royal College of Paediatrics and Child Health, which provides basic
training in understanding psychological difficulties for all doctors as part of
their training in paediatrics and child health.
4.4 Strategic work and policy development
Paediatric clinical psychologists contribute to the development of policy and
guidelines at a local and national level. Examples of this include developing
multidisciplinary guidelines, or protocols for specific clinical areas. These may
be developed for the specific needs of the local population or applied more
widely. For example, the Paediatric Psychology Network (PPN) has
developed evidence based practice guidelines for managing invasive or
distressing procedures and these have been disseminated nationally to
relevant organisations including the Royal College of Nursing and The Royal
College of Surgery. Paediatric clinical psychologists provide input and
expertise to inform the development of NICE guidelines for specific areas of
10
child health, for example for childhood eczema, oncology and diabetes, and
offer specialist advice to many national support groups and charities serving
families with children with a range of physical health conditions.
Paediatric clinical psychologists also work with their Trust’s executive teams
to help interpret national standards at a local level, identify service needs and
develop action plans to address unmet need. This may include contributing to
local delivery plans with PCTs and regional commissioners.
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5. HOW ARE PAEDIATRIC CLINICAL PSYCHOLOGY SERVICES
ORGANISED?
The Paediatric Psychology Network (PPN), a network of the Faculty of
Children and Young People within the British Psychological Society (BPS), is
the professional group representing paediatric clinical psychology in this
country and has over 170 members to date. The PPN aims to promote the
development of paediatric clinical psychology, including professional practice,
clinical governance, research and training.
5.1 Models of service provision
The Paediatric Psychology Network completed a national review of paediatric
services nationally in 2007/8, which included responses from 58 services,
including those based in district hospitals, regional hospitals and in community
services. The results indicate that psychology services are organised in a
variety of ways, which can be categorized by the following models.
Fig 1 - Service Model
Paediatric
Psychology /
Integrated within
health teams
5%
9%
Mental Health
Teams
7%
CAMHS
79%

Other
The most prevalent model (79% of services) was that of a dedicated
paediatric clinical psychology service, often based within a specialist
Children’s Hospital/Department (e.g. Sheffield, Bristol, Great Ormond
Street Hospital, Evelina Children’s Hospital, Yorkhill, Alder Hey, Leeds,
Birmingham, Oxford). In this model, psychology sessions are
integrated within one or more multi-disciplinary health teams across a
variety of clinical specialties and in some instances, provide generic
cover across all paediatric specialities or duty systems to cover all
inpatient services
12

A further 7% of psychology services to paediatrics described
themselves as being integrated within a broader multidisciplinary
mental health service (e.g. North Middlesex, Manchester) for example
in a psychiatry liaison service or integrated mental health service.
These teams often have a mental health remit as well as working with
children with a physical illness and include services such as risk
assessment following self harm.

9% of clinical psychology services to paediatrics were based in Child &
Adolescent Mental Health Services (CAMHS) providing:
(i) Locality based services for children with medical conditions as part
of general CAMHS caseload (e.g Cambridgeshire) or with special
clinics/dedicated sessions for these referrals (e.g Cystic Fibrosis
service in Carshalton).
(ii) Sessional input to local DGH as uniprofessional psychology service
or part of a CAMHS Liaison service (e.g. Coventry, Staffordshire).

5% of clinical psychology input included community based palliative
care/ life threatening illness teams (e.g. the Diana Teams)
In terms of the location of services, 90% of regional/national services were
hospital based, with the remaining 10% being specialist services that were
based within their specialist teams outside of the hospital setting (e.g Bath
Pain Management unit). 70% of psychology services to district hospitals were
hospital based.
Most regional services (95%) have either dedicated
psychology sessions to particular specialities or a mixture of dedicated and
generic sessions. In district hospitals and those served by liaison services, a
predominant model of generic sessions was evident.
Within current paediatric clinical psychology services, there were notable
differences in organisation between district and larger regional hospitals. For
example, 75% of psychology services in specialist/regional hospitals were
both managed and funded by the hospital trust, whereas management was
shared equally by CAMHS and hospital trusts in district hospitals. Funding for
specialist areas of work came from both PCTs, hospital trusts and CAMHS
but with much greater funding for generic work from CAMHS.
To date there has not been a systematic evaluation of models of service
provision. Feedback was elicited from the Heads of the psychology services
who participated in the survey regarding their views about an optimal service
model, and 86% supported a paediatric clinical psychology service which is
hospital based, integrated within the multi disciplinary health team(s), and
which has good access to a mental health service, either a psychiatry liaison
team or CAMHS.
Respondents reported that the distinct advantages of the predominant model
include greater accessibility and responsiveness to referrals, effectiveness of
13
working relationships within the multi-disciplinary health team, opportunities
for early intervention/ proactive work and joint research within the health
teams.
The few challenges reported with this model were more evident in services
with fewer dedicated psychology sessions, and services that were based
outside of the hospital. These included challenges in meeting clinical
demands, funding difficulties and limited access to service developments.
Also, challenges in maintaining effective links including difficulties referring on
to local CAMHS (as cases often did not meet the threshold for referral
criteria). In services with mixed management (acute health and mental
health), there were reported challenges around clinical models and
service/funding priorities reflecting management conflicts between acute
health trust and CAMHS management.
The Division of Clinical Psychology advises that service models should reflect
the needs of the population served, local resources and structures and ensure
patient safety through appropriate professional and clinical governance
structures. All paediatric clinical psychologists are required to have
appropriate professional supervision and it is important that professional
management is effectively linked to service management to ensure resources
are used as effectively and efficiently as possible.
5.2 Workforce planning
Please refer to Appendix 1 for examples of bids made to secure psychology
time within paediatrics, including identifying the number of sessions required.
In order for a paediatric clinical psychologist to provide an effective, safe,
evidence based service to a multi-disciplinary paediatric medical team, time is
required for the following:

Direct clinical work with children & families

Consultation to and liaison with the health and social care systems
around the child

Activities relating to clinical governance (including audit & research)

Continuous Professional Development
In 2001, the BPS recommended a minimum of 2.0 wte clinical psychologists
to input to paediatrics for a population of up to 250,000, but this figure did not
take account of specialist or supra regional paediatric services.
14
The results of the PPN National Survey indicated considerable diversity in the
clinical psychology provision within paediatric services. The range nationally
was 0.2 – 18.3 wte psychology posts. Within specialist/regional children’s
hospitals/departments a mean of 5.2 wte posts was reported and services to
district general hospitals provided a mean of 1.0 wte posts.
Some clinical specialties have developed their own recommendations
regarding levels of psychology provision. For example, the Cystic Fibrosis
Trust guidelines recommend 0.4 wte of a paediatric clinical psychologist per
50 patients. Within renal services, the BAPN (British Renal Unit Survey)
recommends a minimum of 0.3 wte of psychology time (2 sessions for direct
work and I session for consultation) per million population. Within Cleft
services, the workforce recommendation is for 1 wte per 250,000 population
(approx 150 births with Cleft lip and Palate). A Dutch working party of
paediatricians and psychologists recommended 0.3wte psychology input for
each paediatrician, based on a review of how many children were referred to
paediatric clinical psychology services.
15
6. WHAT EVIDENCE IS THERE THAT PAEDIATRIC CLINICAL
PSYCHOLOGISTS ARE EFFECTIVE?
There is a good evidence base to support the clinical effectiveness of
psychological interventions for a number of medical conditions and illnesses
(Spirito and Kazak, 2006, Drotar et al, 2006). However, at present, there is
less research on the cost effectiveness of these types of intervention.
6.1 Clinical Effectiveness
A recent review by Spirito and Kazak (2006) summarises the evidence base
for interventions in paediatric clinical psychology based on peer reviewed
research papers and some examples from this are summarised here.
Empirically supported treatments include the use of cognitive behavioural
therapy (CBT) for managing pain, including procedural pain (Powers, 1999)
and recurrent abdominal pain (Janicke and Finney, 1999) and for managing
symptoms with no known organic cause (Powers, 2005). CBT has also been
found to be effective in a number of other interventions for children with a
chronic illness e.g. for adolescents with cystic fibrosis (Hains et al, 1997) and
for asthma. CBT is also effective in managing symptoms of anxiety or
depression associated with chronic illness (Kaminsky et al, 2006).
A combination of CBT and systemic techniques has been shown to be
effective in reducing stress symptoms in cancer survivors and their parents
(Kazak et al, 2004).
Relaxation and self-hypnosis was shown to be effective in the management of
pediatric headache (Holden, Deichmann & Levy, 1999).
Behavioural therapy can be effective for some problems such as enuresis and
encopresis (Mellon and McGrath, 2000, McGrath et al 2000) and for some
feeding and eating problems (Benoit et al, 2001).
Behavioural and multi component therapy has been shown to be of benefit in
improving adherence to treatment (Lemanek et al, 2001).
6.2 Cost Effectiveness
Research on psychological influences on health care use has shown that
there is a link between psychological distress and increased use of health
care. For example, Goldman and Owen (1994) showed that high levels of
anxiety increased use of health care resources and therefore increased the
cost of treatment. Cote et al (2003) showed that children with diabetes who
have associated low mood have higher utilisation of health services. The
psychological well being of medical patients has an impact on treatment and
recovery, and therefore addressing these psychological factors may result in
16
reduced overall costs of treatment through shorter length of stay. In addition,
psychological interventions for procedural fear or anxiety can enable a
procedure to go ahead rather than be cancelled, helping to maximise efficient
use of resources.
At present, very few studies have quantified the cost of psychological
intervention in order to identify any benefit in terms of medical cost offset.
These benefits may include better use of health resources (such as higher
levels of adherence, higher attendance at clinic appointments) resulting in
lower medical costs through reduced complications in long term (Lemanek et
al, 2001). Indirect cost benefits also include improved staff retention and a
reduction in the number of days sickness reported when staff feel well
supported in their work.
Examples of paediatric studies which have included an evaluation of the
medical offset cost of psychological intervention include a study of
motivational techniques with adolescents with diabetes (Channon et al, 2007).
A controlled trial of multisystemic therapy for diabetes demonstrated reduced
inpatient admissions and significantly lower care costs for adolescents with
poorly controlled diabetes (Ellis et al, 2005). Holmes, Walker, Llewellyn and
Farrell (2007) showed that the cost of providing a transition care programme
was covered by the cost savings made through fewer admissions to hospital.
Within clinical health psychology focusing on adult patients, there is a more
robust body of evidence from studies demonstrating cost effectiveness.
These include Chiles, Lambert and Hatch (1999), who carried out a meta
analysis of psychological interventions and estimated that the medical cost
offset was around 20%. Another study looking at psychological assessment
within plastic surgery, showed that effective assessment reduced the number
of patients proceeding to surgery, resulting in cost savings that recouped the
salary of a psychologist (Clarke et al, 2005). Studies have demonstrated the
cost effectiveness of CBT in pain management in the adolescent and adult
sickle cell population (Thomas, 2001) and interdisciplinary pain management
(involving psychological therapy) in spinal pain treatment (Hatten, 2006).
“Medical Crisis Counselling” (Koocher et al, 2001) has also been
demonstrated to be cost effective in reducing distressing psychological
symptoms accompanying a diagnosis of chronic illness (i.e. there were no
increases in overall medical costs and some decreased mental health
utilisation costs).
Generally, psychological interventions can result in fewer cancelled or
delayed medical procedures through universal management strategies for all
children from extra help from play specialists (often supervised by
psychologists) to direct intervention by psychologists for more complex cases.
The cost benefits of this are evident to Trusts through greater through put and
more funds from ‘payment by results’
17
7. SUMMARY AND CONCLUSIONS
Paediatric clinical psychologists are uniquely positioned to provide a breadth
of interventions along the multiple care pathways for children and young
people with physical and health needs. They are able to work collaboratively
alongside other health care providers taking a lead in promoting a
psychologically informed perspective to improve the quality of care and health
outcomes.
Paediatric clinical psychology is a rapidly developing field of applied
psychology within health care. This has resulted in improved integration of
psychology within paediatric health service provision and strategic
development of services which is integral to providing quality, holistic services
for children in line with key DOH and NHS targets.
The PPN can provide further information and can be contacted via the chair of
the committee, Melinda Edwards : melinda.edwards@gstt.nhs.uk
18
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Lemanek, K., Kamps, J. and Chung, N. (2001) Empirically supported treatments in
pediatric psychology: Regimen adherence. Journal of Pediatric Psychology, 26, 25375.
McGrath M.L., Mellon, M.W., Murphy L. (2000) Empirically Supported Treatments in
Pediatric Psychology: Constipation and Encopresis. Journal of Pediatric Psychology,
25, 225-254.
20
Mellon, M.W. and McGrath, M.L. (2000) Empirically Supported Treatments in
Pediatric Psychology: Nocturnal Enuresis. Journal of Pediatric Psychology, 25, 193214.
Meltzer, H., Gatward, R., Goodman, R. and Ford, T. (2000) Mental health of Children
and Adolescents in Great Britain. The Stationery Office, London.
Paxton, R. and D’Netto, C. (2001) Guidance of Clinical Psychology workforce
planning. Division of Clinical Psychology Information leaflet (6). The British
Psychological Society.
Powers, S. (2005) Behavioural and Cognitive behavioural interventions with pediatric
populations. Clinical Child Psychology and Psychiatry, 10, 65-77
Powers, S. (1999) Empirically supported treatments in pediatric psychology.
Procedure-related pain. Jnl of Pediatric Psychology, 24, 131-145.
Robins, P., Smith, S., Glutting, J. and Bishop, C. (2004) A randomised controlled trial
of a cognitive behavioural family intervention for pediatric recurrent abdominal pain.
Jnl of Pediatric Psychology, 30, 656-666.
Spirito, A. and Kazak, A. (2006) Effective and Emerging treatments in pediatric
psychology. New York: Oxford University Press.
Thomas, V., Gruen, G. and Shu, S. (2001) Cognitive –Behavioural Therapy for the
Management of Sickle Cell Disease Pain: Identification and Assessment of Costs.
Ethnicity and Health 6 (1): 59-67.
21
Appendix
Example bids for paediatric clinical psychology posts
Clinical Psychology Input to Neurosurgery
March 2004
Following extensive consultation, it has been agreed that a new post for the provision
of clinical psychology to Neurosurgery will be established, supported by funding from
the Neurosurgery Modernisation group.
The table below lists the psychological needs of the children and families within main
diagnostic groups with an estimate of clinical psychology time required.
Diagnostic category
No.
children
Psychological
problems
1.Hydrocephalus
80

approx/year
Intervention
required
impaired
cognitive
functioning
and learning
difficulties

psychometric
assessments &
recommendations
for special
educational needs

attention
problems

as above

procedural
anxiety
related to
repeated
admissions
for surgery

desensitisation
and coping
strategies

psychological 
adjustment to
shunt
coping strategies
for child and
parents

difficulties
with social
interaction
and peer
relations


behaviour
problems

social skills
training,
strategies for reintegration to
school, liaison
with local
services
cog/ behav
management
(CBT) for child
and parents

22
Estimate of
time needed
1 day/week
Diagnostic category
2. Tumours
3. Epilepsy
No.
children
80 new
cases/yr
Psychological
problems
Intervention
required

procedural
anxieties

as above

post surgical
anxiety and
associated
behav. probs.
related to
short term
effects of
brain trauma

coping strategies
for child and
family, liaison
with local services

intellectual

and functional
impairment
associated
with
neurological
deficits
psychometric
assessment with
management
advice

behaviour and 
personality
changes
cognitive
behavioural
management for
child and parents
(CBT)

depression
and low selfesteem

self –esteem
training

behavioural
changes

functional
assessment and
management


adjustment to
significant
neurodevelop
mental
deficits
rehabilitation
coping strategies

CBT for child,
advice to parents,
school

behav.
problems on
ward and at
home
23
Estimate of
time needed
1 day/week
1 day/week
Diagnostic
category
4. Road
traffic
accidents
No.
children
1/ month
Psychological
problems


intellectual
changes as
result of major
brain trauma
behaviour
changes
Intervention
required

psychometric
assessment and
advice, as above

behav analysis/
CBT

family work
coping strategies
consultation to
schools


Estimate of
time needed
0.5 day/week
family
adaptation to
damaged child

5. Others eg
spinal surgery,
cysts,
abscesses,
haemorrhage,
congenital
abnormalities
reintegration to
school
 cognitive/behav
ioural changes
 adaptation to
treatment and
outcome

as above

as above
Other activities: research and development 0.5 days/week
psychosocial meeting 1 hr/week
neuro-oncology meeting 1.5 hrs/week
professional eg psychology dept meetings, supervision
Total time: 5 days/week, 1.0 WTE
Proposed Grading: Band 8b
24
0.5 days/week
Bid for Paediatric Clinical Psychologist within Cardiac Services
Role
Project sponsor
Project lead / manager
Management Accountant sign-off
Name
Title
Clinical Unit Manager
Psychologist
Management
Accountant
Statement of purpose: Brief description of what you are proposing
The purpose of this investment proposal outline is to demonstrate the need for 1 Whole Time
Equivalent (wte) Clinical Psychologist at Band 8b within Cardiology; the post would be 0.5
clinical, 0.5 staff support.
Currently there is no staff support service and Cardiac Nursing sickness rate is running
above the trust average; this has resulted in and has resulted in 1052 missed shifts since the
start of the calendar year and, at the end of month 4, the Unit has spent £171,882 on Agency
Nursing.
Increasing the capacity of the service from 0.4 to 1.4 wte would provide significant
improvements in three main areas;
- the development of a staff support service in order to reduce stress and reduce the amount
of short and long term sickness amongst the Cardiac Nursing Staff
- provide greater equity to children and families who require the service
- develop a psychosocial research strategy for the Cardiology to Service to improve the
quality and capacity of cardiology research
NHSProfessionals (NHSP) have been unable to fill all these shifts which has meant that
either beds have been staffed with insufficient numbers, or closed.
The large number of unfilled shifts has meant that beds have had to be closed and this has
resulted in a decrease in throughput in the unit and a loss of income.
Furthermore, the additional psychologist would contribute to effective decision making and
unit policy development and enable greater provision of education to health professionals,
both nationally and internationally.
Strategic context:
Please describe your proposal and how it meets the criteria that will be used to score you
proposal. Where you have material to add against criteria, please use all the space you need
under the heading.
Scoring criteria for all other bids
Staff
Due to a long-term issue with high levels of sickness a stress survey was undertaken for the
nursing staff by an external provider. The findings highlighted three areas which needed to
be addressed;
 “I am unable to take sufficient breaks due to demands/pressure on me”
 “Different groups at work demand things from me that are hard to combine”
 “Workload is too much to obtain job satisfaction”
25
A number of away days were held with Band 7 nurses in order to address the issue in the
short term. One of the goals of this exercise was to provide the Band 7 nurses with tools to
address stress issues on the ward.
The department is putting in another bid to increase nursing levels within the unit and the
provision of a staff support service is a necessary development to ensure both that there is a
suitable structure in place to support both existing and any new staff within the cardiothoracic
unit.
The provision of a staff-specific psychological services would address these issues, reduce
both the sickness rate and hence reduce the amount of agency staff used, the number of
unfilled shifts and the number of shifts which have been staffed under optimum levels of
staffing.
For the size group of the staff, above 150, it is necessary for 0.5 wte to be dedicated to
setting up, providing and monitoring the service.
Members of Paediatric Intensive Care Units are at risk of feeling burned out and
disempowered as they are confronted with issues of life and death, reduced quality of life,
children in pain and distress and their emotionally overwhelmed families as evidenced by
studies (Gehring, Widmer, Banziger & Marti, 2002 and Meyer, De Maso & Koocher, 1996).
The challenges posed necessitate supervision and specific training to increase individual
coping and stress management as well as enhance team development, and can be provided
by experienced clinical psychologist.
The high levels of agency staffing is not only expensive but provides a degree of
discontinuity in the quality of care offered and increases levels of stress amongst existing
experienced staff. A major indirect impact of this has been the inability to staff beds which
has impacted on Waiting List, 18 Week and Theatre Utilisation targets.
Clinical
The literature suggests that 25%-40% of children with CHD meet criteria for ‘caseness’ or
clinically significant levels of anxiety or low mood. Anxiety and low mood, if
unidentified/untreated can interfere with adherence to treatment and increase demand on
services through increased preoccupation with symptoms. This is particularly true in
cardiology where breathlessness, dizziness and palpitations mimic cardiac symptoms. In
these cases patients need to be seen by a psychologist integrated within the cardiac
multidisciplinary team.
Research carried out by the current post-holder in the Hypertrophic Cardiomyopathy Clinic,
which saw 609 patients last year, demonstrated that 20%, 121 patients, of affected children
showed clinically significant levels of anxiety and low mood at that time point.
There is no clinical psychology provision for these patients.
A conservative estimate is that 20% of children presenting in cardiology will have clinically
significant levels of distress which may interfere with treatment, adjustment, adherence and
exacerbate/mimic heart symptoms.
Increasing our clinical psychologist service by 0.5 wte would mean that approximately 40% of
patients who be able to be seen by the psychologist; currently there is only capacity to see
less than 20% of patients.
Although there would still be a large degree of unmet need this increase in capacity would
allow more effective identification, prioritisation and treatment of psychological difficulties.
Patients would be prioritised based on existing guidelines.This is a group of patients which
have been identified as requiring psychological support, yet the sample size is representative
of less than 1% of all patients seen within the cardiothoracic unit during 06/07. It is therefore
difficult to quantify the level of unmet clinical need and therefore determine clinical priorities
however, patients treated in the Hypertrophic Cardiomyopathy Clinic would be prioritized by
the new postholder.
26
Research
The Unit Lead is keen to develop multidisciplinary research and psychosocial research. The
current post holder has insufficient time to coordinate this or increase the capacity and profile
of the multidisciplinary research. This is a particular shortfall on a unit where there are unique
treatments and opportunities for novel research with new patient groups and existing patient
groups
Outline of demand and capacity issues.
There is currently no support service for the nursing staff and this need has been identified
through the staff stress survey and a staff questionnaire carried out by the current postholder
and ECMO Coordinator has highlighted that staff are keen to have regular support.
The current capacity of the psychological service for children/families is 0.4 wte post which
covers Cardiac Critical Care, Ladybird Ward, ECMO and Cardiac Outpatients with waiting
times varying between 2 to 12 weeks. The current level of provision means that the wards
have no cover for 5 days of the week and there is no cover when the postholder is on annual
leave / study days.
A recent audit of clinical psychology provision to cardiology found that there is a capacity for
117 new cases (261 appointments), which is less than 1% of cardiology patients (7315 for
06/07). In addition, the majority of referrals were found to have come from 2 consultants.
With the Psychologist able to provide a service to fewer than 1% of children presenting, there
is a significant risk that many children’s needs are not being met.
Another clinical psychologist would mean that another 195 appointments would be available
meaning that 456 appointments would be available which would reduce the waiting list to 7
weeks.
The existing 0.4 wte post covers Cardiac Critical Care, Ladybird, ECMO and Cardiac
Outpatients. Consequently the waiting list for psychology is significantly affected by the rate
of referrals, with waiting times varying from 2 weeks to 12 weeks.
0.4 wte means that the wards have no cover for 5 days of the week and that
inpatients/families in crisis can wait up to 5 days to be seen and there is no cover when the
psychologist is on annual leave.
27
Financial Summary (a completed breakdown should be included with the
proposal)
Year
Capital Costs
Revenue Costs
Non-recurring revenue costs
Income expected from related
activity
Planned revenue savings
First Year
Recurring
£31,317
£62,635
£58,930.97
Budget breakdown: Please show the broad cost headings for the investment.
 Staff Costs
 Equipment costs
 Maintenance Costs
 Consumables Costs
 Training Costs
 Installation Costs
Please ensure VAT is added to the costing, including for Medical Equipment bids.
Mid point of Band 8b (Pay point 41) is £62,635 including High Cost Area Allowance & on
cost.
Therefore, allowing for recruitment, 6 months of 1.0 wte Band 8b is £31,317
Dependant on timely recruitment we estimate that it would take 2 months for the service to
be set up – at this moment it is difficult to quantify the savings which could be expected
within the first year.
Outcomes Brief outline of how you will demonstrate that the investment has
generated the benefits that you intended, for example details of performance
indicators, satisfaction measurement, evidence of clinical effectiveness,
reduced risks. Please tell us, where appropriate, why it isn’t possible to
demonstrate clearly the benefits from an investment
The efficacy of clinical supervision and its effect on job satisfaction and quality of patient care
has been shown to be enhanced by nursing staff being given both supervisor and supervisee
roles as well as training in clinical supervision (Hyrkas, Appelqvist-Schmidlechner and
Haataja, 2006.) Setting up such a system would require some further evaluation of the
needs of the target staff group as the supervision needs of staff have been found to vary with
grade (Butterworth et al., 1999) and experience (Hyrkas et al., 2006.)
In addition, a system of assessing the quality and effectiveness of the staff support provided
would need to be built in from the start and continually monitored, since the effectiveness of
clinical supervision and staff satisfaction with supervision has been shown to increase after
2-5 years (Butterworth et al., 1999.) The staff support strategy will be evaluated with pre and
post measures of staff stress, job satisfaction and patient satisfaction using standardised
measures as well as specific goal setting by staff.
It is therefore difficult to quantify the impact of the service but it estimated that spend on
Agency Nursing will decrease by 20%. This would result in a £58,930.97 saving annually,
based on projections from this year’s spend on agency staffing. As this is based on the
staff support aspect of the post this is the saving on 0.5 of the post (i.e. £31,355.) The
clinical part of the position would be providing indirect benefit to the unit in terms of
throughput; this is difficult to quantify and linked more closely with the Cardiothoracic Unit’s
28
bid to increase
staffing and throughput.
The part of their role the postholder will be expected to undertake a needs assessment, put
in place appropriate systems dependent upon the results of the needs assessment and
undertake an ongoing evaluation this process
Clinical Outcomes / benefits for patients:
The early identification and treatment of mental health issues that interfere with or mimic
cardiac symptoms will ensure that psychological and developmental issues are taken into
consideration in multidisciplinary team and family decision making. This will enable the
supporting of patients and families who have significant difficulty adjusting post-operatively
(e.g. reactive depression following ICD insertion, health anxiety following cardiac surgery,
reduced function or mobility that cannot be explained by the objective health status)
Outcomes and performance management will be measured through Board/Monitoring
reports:
 Monitor the number and diagnosis of patients seen by a psychologist
 Sickness and absence monitoring
 Activity targets
 Income target
 Theatre utilisation
29