Undertaking an extended role in child and adolescent mental health

Step 1: Reappraise core knowledge

GPs who have completed specialty training have the skills to consult with a child or young person, and their families or carers, in a way which makes them feel heard and validated, seeks to identify their concerns and expectations, and communicate in a way that is understandable and accessible. All GPs should be able to recognise mental health problems in children and young people (CYP), and manage, refer and/or signpost appropriately. 

The RCGP Curriculum details the core knowledge and skills expected of all GPs. These are covered both under the Mental Health Clinical Topic Guide and the Children and Young People Life Stages Topic Guide. 

Overarching knowledge and skills relate to the recognition of mental health presentations as well as the spectrum of normal childhood experiences, appreciation of the biopsychosocial influences on the mental health and wellbeing of CYP, the ability to conduct an assessment and consider a risk formulation as part of this, recognise the strengths of the CYP and the people or situations around them which contribute positively to wellbeing, and to work alongside other agencies to signpost to or deliver mental health care at an appropriate level.

Step 2: Familiarisation with Diagnostic Classification Systems

The GPwER CAMH should be familiar with the administration of the relevant diagnostic classification systems for mental health problems in CYP. The recognised criteria should be used to support differentiation between presentations, and develop a formulation to guide best practice and optimal treatment for the CYP, in the context of their individual preferences and needs.

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR)

DSM-5-TR was published by the American Psychiatric Association in 2023 and is useful in defining and classifying mental disorders, with the intention of improving diagnoses, treatment and research.

The International Classification of Diseases 11th Revision was published by the World Health Organization in 2022 and offers diagnostic criteria for a variety of conditions, providing a common language for the recording, reporting and monitoring of disease.

Step 3: Revise, update and consider national and international guidelines

National guidelines continually evolve, with updates and new publications. The GPwER should be aware of guideline publications and updates. Key sources of information include:

• National Institute for Health and Care Excellence (NICE) 
• Scottish Intercollegiate Guidance Network (SIGN)
• British Association for Psychopharmacology (BAP)
• Medicines and Healthcare products Regulatory Authority (MHRA) 
• Specialist Pharmacy Service (SPS)

Step 4: Acquire experience in a CAMHS Clinic and a Mentor

Key conditions that may be encountered in the work of the GPwER (depending on individual competence and with specialist support where needed) include:

• Anxiety
• Bipolar disorder
• Depression
• Eating disorders
• Personality disorders
• Psychosis
• Schizophrenia
• Self-harm
• Suicide prevention
• Trauma-informed care and adverse childhood experiences (ACEs)

Neurodivergence and substance misuse disorders are covered in separate GPwER frameworks, but an enhanced level of knowledge appropriate to the role as a GPwER CAMH is required due to the likelihood of coexistence of conditions.

Delivery of care can be in a variety of settings, including, but not limited to: 

• GPwER working within primary care
• GPwER working within a child or adolescent mental health clinic
• GPwER working within paediatric clinics
• GPwER working within a psychiatric team of experts, including psychiatrists, psychologists, and behavioural therapists
• GPwER working within community mental health teams
• GPwER working within integrated care teams

This role is relevant to CYP up to the age of 18, with transition between CYP and adult services taking place between 16-18 years. In some areas, an older population is covered, often up to the age of 25.

Referrals to the GPwER CAMH may originate from various sources including:

• Other GPs or members of the primary care team 
• Paediatricians
• Educational Institutions (schools, colleges) and Early Years services
• Teachers, Special Educational Needs coordinators, educational psychologists, behaviour support teachers
• Mental health professionals
• Psychologists, therapists, or counsellors
• Public health services
• Specialised clinics or medical centres
• Neurologists
• Community health services
• Legal organisations, police and the criminal justice system
• Social services, including safeguarding and Early Help services
• Specialists in various fields, such as allergists, speech-language pathologists, or developmental paediatricians
• Self-referral
• Private practitioners and therapists

The referrals will be influenced by the nature of the healthcare system, the availability of specialised services, local practices, and the specific circumstances and needs of the patient.

Collaboration among different professionals is often key to providing comprehensive care. 

The role involves working with, or leading, teams who deliver care for CYP with mental health difficulties.

Settings in which the GPwER CAMH may work include:

• Primary or secondary care or private health care, across a healthcare system depending on need and local resources.
• Working independently or in conjunction with other services.
• Providing initial assessment, referral, and ongoing support in the form of shared care with secondary care providers, or engaging in full diagnosis and ongoing management, with access to secondary care specialist advice when required.
• Attending regular and ad hoc (in-person or remote) meetings with other clinicians either on their own or with patient(s) and carers.

Patients are accepted by referral from a variety of sources as detailed in the section ‘Patient population’.

The GPwER CAMH works autonomously as a GP, but governance may vary depending on the organisation delivering the service. 

The GP appraisal covers the whole scope of a GP’s practice. This ensures GPs with extended roles, including those managing CAMH, maintain a high standard of care, engage in continuous professional development, and provide effective and safe services to CYP with mental health difficulties. It promotes accountability, improvement, and excellence in a GP's specialised areas of practice.

As a GP, the GPwER CAMH should bring evidence that they are maintaining competence in this role to their GP appraisal. GPwERs employed outside of their Practice should include a performance review by their employer or line manager and they should provide the outcomes as part of their whole scope of practice in their appraisal portfolio.

They should:

1. Be able to evidence how they qualified for this role.
2. Evidence their performance, ongoing professional development, and engagement. This evidence may include patient cases, audits, educational activities, and feedback from patients and colleagues.
3. Reflect on their experiences, challenges, and successes in managing cases. Reflective discussions help identify areas for improvement and develop strategies to enhance their practice and patient care.
4. Obtain feedback from peers, colleagues, multidisciplinary team members, and patients in line with GP appraisal requirements.  It may be appropriate for a GPwER to demonstrate feedback in their role with colleague and/or patient surveys in addition to their surveys as an NHS GP.
5. Maintain a CPD portfolio that documents their participation in relevant educational activities, courses, conferences, and workshops related to their GPwER role. This portfolio showcases a commitment to ongoing learning and development.

GP appraisal provides assurance to the Responsible Officer (RO) that the GPwER:

• has trained for their role as a GPwER
• is staying up to date in that role
• is seeking and reflecting on feedback and outcomes in that role including the outcomes from a performance review with a line manager or medical director or employer.

GPs with extended roles usually undergo revalidation usually every five years, to maintain their licence to practise.

Indemnity

GPwER in CAMH who initiates, prescribes and monitors medication for children and adolescents are strongly recommended to discuss their role and insurance arrangements with their medical defence union.

The GPwER may interface with: 

• General practices – individually or as part of a network, alliance or federation
• Secondary or tertiary care community or inpatient services, depending on co-morbidities, severity and risk
• Educational establishments
• Voluntary/third sector organisations
• Pharmacists
• Local authorities and safeguarding services
• Public health services
• Integrated care boards, local health boards, local neighbourhood teams
• Occupational therapists
• Private medical services
• Criminal justice system

The time commitment for a GPwER CAMH; is flexible, ranging from a single session (per week) to a full-time role.

The GPwER CAMH may be self-employed or employed by a hospital trust, integrated care board, primary care or cluster network (or equivalent in the devolved nations), private healthcare service or other service providers.  The GPwER CAMH may be a partner, a salaried GP, or a sessional GP. Their contract is likely to stipulate that they are a GP and their role or part thereof is to provide CYP services.