Publication - Advice and guidance

National Specification for psychological therapies and interventions: self assessment tool

Published: 25 March 2026
From: Minister for Social Care and Mental Wellbeing, +1 more … Cabinet Secretary for Health and Social Care
Directorate: Mental Health Directorate
Topic: Health and social care
ISBN: 9781807750855

Self Assessment Tool to help services assess delivery of psychological therapies and interventions against the National Specification outcomes.

Supporting documents

PT Specification self assessment tool

Outcome 1 – High quality care and support
1.A
Anyone referred and seen by a staff member trained at enhanced and specialist practice for psychological treatment or interventions has their contact with services recorded on the waiting times standard.
Examples/ Guidance	Current activity and evidence: include areas of strength and areas for development	Current status
Data derived from health intelligence IT system that lists what is included and what is recorded Internal surveys are used to check data compliance	N/A	Please score: 1 = red – not met 2 = amber – partially met 3 = green – fully met

Outcome 1 – High quality care and support
1.B
All staff providing psychological therapies at enhanced and specialist practice are registered with the relevant professional body where appropriate.
Examples/ Guidance	Current activity and evidence: include areas of strength and areas for development	Current status
Staff database including professional affiliation eESS system	N/A	Please score: 1 = red – not met 2 = amber - partially met 3 = green – fully met

Outcome 1 – High quality care and support
1.C
Protocols are in place to make sure staff offering psychological treatments and interventions receive regular clinical supervision and follow guidance in the psychological therapies Matrix.
Examples/ Guidance	Current activity and evidence: include areas of strength and areas for development	Current status
Department protocol in place Audit of supervision on yearly basis/as part of ADR?	N/A	Please score: 1 = red – not met 2 = amber – partially met 3 = green – fully met

Outcome 1 – High quality care and support
1.D
Where treatment is offered, outcome measures are routinely used (minimum of every first and last appointment) to measure people's progress and it informs treatment planning.
Examples/ Guidance	Current activity and evidence: include areas of strength and areas for development	Current status
Derived data sets (assuming IT infrastructure allows reporting) What measures, how recorded? Annual reporting of outcomes? Mandatory data set	N/A	Please score: 1 = red – not met 2 = amber – partially met 3 = green – fully met

Outcome 1 – High quality care and support
1.E
There are clear referral criteria including how urgent referrals (where appropriate) are managed for all psychology teams and services.
Examples/ Guidance	Current activity and evidence: include areas of strength and areas for development	Current status
Psychology/PT Service SOP’s Referral guidelines and how accessed by internal and external agencies as well as public	N/A	Please score: 1 = red – not met 2 = amber – partially met 3 = green – fully met

Outcome 1 – High quality care and support
1.F
Teams and services have an improvement plan in place to reduce unnecessary delays and unequal waits (e.g., improvement plan and trajectory).
Examples/ Guidance	Current activity and evidence: include areas of strength and areas for development	Current status
Regular Board or Meeting established for this purpose Improvement plan Trajectory modelling Reporting structures internal to board on progress	N/A	Please score: 1 = red – not met 2 = amber – partially met 3 = green – fully met

Outcome 1 – High quality care and support
1.G
Teams and services have the necessary information technology and data systems.
Examples/ Guidance	Current activity and evidence: include areas of strength and areas for development	Current status
IT system used Accuracy of system assurance	N/A	Please score: 1 = red – not met 2 = amber – partially met 3 = green – fully met

Outcome 1 – High quality care and support
1.H
Information and Data systems are fit for purpose.
Examples/ Guidance	Current activity and evidence: include areas of strength and areas for development	Current status
IT system used Accuracy of system assurance Completeness of CAPTND dataset returns to PHS	N/A	Please score: 1 = red – not met 2 = amber – partially met 3 = green – fully met

Outcome High quality care and support
1.I
Peer support worker roles have been considered as valuable team roles in psychological services.
Examples/ Guidance	Current activity and evidence: include areas of strength and areas for development	Current status
Evidence of existing peer support roles and/or minutes from PT improvement Boards/Meetings where peer roles have been considered As part of vacancy planning peer support roles have been considered	N/A	Please score: 1 = red – not met 2 = amber – partially met 3 = green – fully met

Outcome 2 – People are fully involved in decisions
2.A
Following referral, an initial contact appointment is offered to the person seeking help within 12 weeks to discuss their needs.
Examples/ Guidance	Current activity and evidence: include areas of strength and areas for development	Current status
Service Standard Operating Procedures (SOPs) Waiting list management protocols	N/A	Please score: 1 = red – not met 2 = amber – partially met 3 = green – fully met

Outcome 2 – People are fully involved in decisions
2.B
Once treatment has started, appointments are on a regular basis according to need (i.e., there is no hidden internal wait for treatment).
Examples/ Guidance	Current activity and evidence: include areas of strength and areas for development	Current status
Transparent reporting on processes across services if and when assessment appointments are used Measure time between assessment and T1 session CAPTND	N/A	Please score: 1 = red – not met 2 = amber – partially met 3 = green – fully met

Outcome 2 – People are fully involved in decisions
2.C
If the person needs treatment from an appropriately trained professional, they will be offered and recommended the treatment options that are most suitable for them (e.g., digital, or group, or individual).
Examples/ Guidance	Current activity and evidence: include areas of strength and areas for development	Current status
Screening and treatment allocation protocols? Service SOPs	N/A	Please score: 1 = red – not met 2 = amber – partially met 3 = green – fully met

Outcome 2 – People are fully involved in decisions
2.D
If the person has not been seen in the 18-week referral to treatment target the team/service has kept in touch with the individual a maximum of every 12 weeks and offered any suitable help if they continue to need to wait.
Examples/ Guidance	Current activity and evidence: include areas of strength and areas for development	Current status
Service SOP’s and regular audit (assuming IT system, reporting and admin is in pace to do so) Waiting list protocol	N/A	Please score: 1 = red – not met 2 = amber – partially met 3 = green – fully met

Outcome 3 – High quality interventions and treatments
3.A
The psychological therapies Matrix is used to guide delivery of treatments and interventions (this is monitored through regular supervision and the clinical care and governance group).
Examples/ Guidance	Current activity and evidence: include areas of strength and areas for development	Current status
Suggested: Awareness raising of Matrix Case note audit Throughput of patients should map onto Matrix (again requires IT systems/personnel to ensure reports are effective)	N/A	Please score: 1 = red – not met 2 = amber – partially met 3 = green – fully met

Outcome 3 – High quality interventions and treatments
3.B
If a psychological therapy recommended to an individual is not listed in the Matrix for that clinical presentation, protocols are in place for the staff member to seek out and receive appropriate advice from a senior practitioner psychologist (e.g., through supervision and line management).
Examples/ Guidance	Current activity and evidence: include areas of strength and areas for development	Current status
Off protocol treatment models – this is monitored via PT governance structures and through the psychological therapies' governance group?	N/A	Please score: 1 = red – not met 2 = amber – partially met 3 = green – fully met

Outcome 3 – High quality interventions and treatments
3.C
Job planning, national guidance and clinical judgement are all used to determine the number of sessions offered to the person seeking help.
Examples/ Guidance	Current activity and evidence: include areas of strength and areas for development	Current status
Job Plans Job plans in place Regular audit of mean, mode and range of PT sessions offered by clinicians Discussed in LM supervision quarterly	N/A	Please score: 1 = red – not met 2 = amber – partially met 3 = green – fully met

Outcome 3 – High quality interventions and treatments
3.D
Each team/service has a protocol in place so that if the person seeking help has not attended their appointment the case is not closed without the service making contact with them.
Examples/ Guidance	Current activity and evidence: include areas of strength and areas for development	Current status
Service SOPs Attendance management protocols	N/A	Please score: 1 = red – not met 2 = amber – partially met 3 = green – fully met

Outcome 3 – High quality interventions and treatments
3.E
The PHS trajectory tool is used in all teams and for overall service planning so that staff work within recommended activity levels.
Examples/ Guidance	Current activity and evidence: include areas of strength and areas for development	Current status
Job plans and activity monitoring systems are in place	N/A	Please score: 1 = red – not met 2 = amber – partially met 3 = green – fully met

Outcome 4 – Rights are acknowledged, respected and delivered
4.A
Ongoing quality improvement is routinely used as part of planning and delivery of psychological practice
Examples/ Guidance	Current activity and evidence: include areas of strength and areas for development	Current status
PT improvement Boards/meetings with demonstrable improvement agenda Quality improvement agenda and action plan	N/A	Please score: 1 = red – not met 2 = amber – partially met 3 = green – fully met

Outcome 5 – People are fully involved in planning and agreeing transitions
5.A
There are processes in place so that communication between professionals is clear for any transitions for people between services.
Examples/ Guidance	Current activity and evidence: include areas of strength and areas for development	Current status
SOPs Transition protocols in place	N/A	Please score: 1 = red – not met 2 = amber – partially met 3 = green – fully met

Outcome 5 – People are fully involved in planning and agreeing transitions
5.B
Referral systems are clear, accessible, and efficient for service and referrer’s needs.
Examples/ Guidance	Current activity and evidence: include areas of strength and areas for development	Current status
SOPs IT systems i.e., Morse and how to use them	N/A	Please score: 1 = red – not met 2 = amber – partially met 3 = green – fully met

Outcome 6 – We fully involve people, their families and carers
6.A
True meaningful and valued feedback and involvement from those with lived experience, and their families, should be a core part of all psychological service delivery. This should be integrated into service delivery as part of regular service planning.
Examples/ Guidance	Current activity and evidence: include areas of strength and areas for development	Current status
QI framework Service user Routine data collection processes are in place Forums established where lived experience views gathered and actioned as appropriate LEAP in place in Board? TOR	N/A	Please score: 1 = red – not met 2 = amber – partially met 3 = green – fully met

Outcome 7 - Confidence in the staff delivering service
7.A
The roles of the professionals in the service or team are available and described in a format and language that people can understand (e.g., webpage).
Examples/ Guidance	Current activity and evidence: include areas of strength and areas for development	Current status
Local service webpage/patient information leaflets etc Service information and how access i.e., webpage etc	N/A	Please score: 1 = red – not met 2 = amber – partially met 3 = green – fully met

Outcome 7 - Confidence in the staff delivering service
7.B
The NHS Board has clear leadership and whole system oversight from a director of psychology (Band 9).
Examples/ Guidance	Current activity and evidence: include areas of strength and areas for development	Current status
Yes/No Leadership Structures	N/A	Please score: 1 = red – not met 2 = amber – partially met 3 = green – fully met

Outcome 7 - Confidence in the staff delivering service
7.C
Director of Psychology is supported to provide guidance about whole systems planning by working with all senior leaders in Health and Social care to provide direction on psychological care and practice.
Examples/ Guidance	Current activity and evidence: include areas of strength and areas for development	Current status
PT governance group?	N/A	Please score: 1 = red – not met 2 = amber – partially met 3 = green – fully met

Outcome 7 - Confidence in the staff delivering service
7.D
Based on leadership from the Director of psychology there is sufficient (enough staff based on trajectory modelling tools) investment in psychological services and teams to meet local service and team demands.
Examples/ Guidance	Current activity and evidence: include areas of strength and areas for development	Current status
DCAQ analysis Trajectory modelling and where reported/frequency/ outcomes and actions	N/A	Please score: 1 = red – not met 2 = amber – partially met 3 = green – fully met

Outcome 7 - Confidence in the staff delivering service
7.E
There is a board wide psychological therapies and interventions governance group led by the Director of Psychology (or designated lead for psychology) to ensure delivery of practice is safe and evidence based.
Examples/ Guidance	Current activity and evidence: include areas of strength and areas for development	Current status
Evidence of established PT/Psychology Governance group PT governance group, Terms of reference	N/A	Please score: 1 = red – not met 2 = amber – partially met 3 = green – fully met

Contact

Email: ptspecification@gov.scot

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