VOL: 103, ISSUE: 16, PAGE NO: 32
Martin McGuinness, MSc, DMS, LLB, RMN, RGN, is registered manager, Astracare (UK) Ltd
Tony Leiba, PhD, RMN, RNT, is chairperson of educational development, London South Bank University, and researcher in mental health, North East London Mental Health Trust and London South Bank University; Caroline Mathiason, LCSLT, MBA, is project manager/care consultant, North East London Mental Health Trust and Goodmayes Hospital, IlfordCommunity mental health teams (CMHTs) have a growing role and responsibilities yet there is little guidance on how ...
Community mental health teams (CMHTs) have a growing role and responsibilities yet there is little guidance on how to manage these teams. The National Service Framework for Mental Health (Department of Health, 1999) outlined the possible make-up of teams, their role in general terms and some numerical benchmarks for caseloads but left it to local mental health trusts to develop working practices. It is important that workloads of CMHT workers are at a level that is safely manageable, both for the worker and the clients whom they support.
A workload weighting system was developed at North East London Mental Health Trust to help teams manage their total workloads. This pilot builds on that work. The aim was to find out if the tool was a reliable way to assess the workload of community mental health professionals.
The literature revealed little evidence of work on defining manageable caseloads in the community, beyond pure numbers with different levels of demand within the total number of cases (Tyrer, 2001; Stein and De Santos, 1998).
Marshall et al (2004) compared case management with standard care in the community but did not address the issue of defining a manageable caseload, while Drennan (1990) devised a system for profiling and comparing district nurse workloads and Onyett (2003) described a caseload-weighting scheme drawing on a framework of client definitions and using a simple three-point weighting scale.
The workload weighting system already in use was adapted slightly and guidelines for its use were strengthened. The system assesses cases on the basis of client risk/vulnerability, coordinating care and time commitment, and also allows for other demands on practitioners' time.
The pilot was undertaken with 11 CMHTs. All members were trained to use the tool and supervisors were asked to see each member of their team to discuss their caseload. Once practitioners had done their first workload weighting supervision session, they were given a questionnaire to complete. Of the 93 possible respondents, 61 returned completed questionnaires.
Nurses outnumbered all other professionals in completing questionnaires; the findings therefore include a large proportion of nurses' views. Indeed, some participants believed the tool did not take account of therapies and targeted mainly nurses.
The average number of clients on a respondent's caseload was 25 (range 12-43). The great disparity in caseloads has implications for staff and services and warrants further investigation.
Answers to questions exploring the training indicated staff clearly understood all aspects of its processes and scoring method - 98% said they fully understood how to use the system.
All questions pertaining to the accuracy of the risk and vulnerability section received 79-89% agreement. However, negative comments included:
'Sometimes due to client reluctance to engage it can be difficult to assess their vulnerability.'
'No clear instructions on balancing act between history and current presentation - what are the parameters? When does history end?'
There was agreement that the coordinating care section of the weighting system reflected the process for recognising and scoring this. All questions in this section received 70-80% agreement.
Staff felt there was a perceived disparity between clients requiring standard care and those requiring enhanced-level care and the amount of care coordination each might require. This reflects the fact that there were differences between teams as to what constituted 'enhanced' or 'standard' care. This will need further investigation if consistency is to be achieved.
Generally the respondents agreed that the time commitment section of the weighting system was representative of the process for recognising and scoring staff time commitment, although the questions gained a 64-69% positive response rate - much lower than previous sections. This section yielded many comments, most relating to indirect contact with clients that is not recorded elsewhere in the tool, such as travel and time spent dealing with other agencies.
When asked whether the listed areas of indirect professional demand accurately represented their additional responsibilities, 52% of respondents agreed while 46% disagreed and 2% recorded a 'don't know'. This clearly highlighted the inaccuracy of the tool in this regard. This section scored the highest percentage of negative scores and generated much discussion during training sessions. A number of comments specified areas that were not accounted for, including:
'ASW (approved social worker) work/back-up duty work and follow-up not accurately accounted for.'
'Non-direct contact, reading up theory and research, preparing a court report case, being called as a witness, attending hearings/tribunals not included.'
'Short-term courses, one-off workshops, informal team supervision, induction of new staff not accounted for.'
Overall effectiveness of the system
Generally, staff from some professions - such as therapists and psychologists - felt that the scoring system did not accurately reflect what they did. Comments included:
'Does not fully represent psychologists' workload, does not represent all workers, targets mainly community nurses.'
'Discriminates against those with many indirect responsibilities.'
'If you have a high caseload you will see clients irregularly but end up with a very high rating.'
Some staff suggested areas for improvement:
'More detailed guidance notes, too open to interpretation, for example in the sections on risk and vulnerability, time commitment and indirect professional demand.'
'Revisit time commitment to include some of the issues raised in the findings, for example administrative meetings and training.'
'Ensure supervision is included in time allowed for both those giving and receiving supervision.'
'Explore differences associated with criteria for standard/enhanced Care Programme Approach (CPA).'
Caseloads varied widely among the teams and further exploration may be needed to understand why this variation exists and what effect it may have on staff and the consistency of the service in general.
The training provided was effective and staff felt it enhanced their understanding of the system. However, some comments suggested that certain sections of the system need to be revisited in the training.
The system worked well for the sections on risk and vulnerability and coordinating care. There is, however, an issue related to the variability of interpretation of clients whose needs are judged to be standard or enhanced. The sections of the system on time commitment and indirect professional demand require further work and revisions.
A number of recommendations were made as to how the system could be improved:
- Consider the issues raised and the suggested improvements made by staff through the training process and questionnaire, and decide which to incorporate into a revised system;
- Roll out training on use of the revised scoring system across CMHTs in the trust;
- The system in its revised form is not appropriate for use in assertive outreach teams; further revision would be needed.
Developments from the recommendations
The steering group agreed the following:
- Extending time commitment beyond direct and telephone contact with clients would make the system too complicated and unworkable;
- Administrative meetings and receiving supervision would be included within indirect professional demand;
- Training was adequately provided for and any extension of this would be complicated and impractical;
- Taking into account the feedback relating to therapy staff, the system could not be modified to adequately address these issues without compromising its intended purpose and use. It was therefore concluded that the system was more suited to use by CMHT workers who carry defined caseloads as CPA care coordinators.
IMPLICATIONS FOR PRACTICE
- This study examined a system to measure the workload of community mental health teams (CMHTs) in a mental health trust. It enabled the trust to understand the tasks of CMHT workers and offers benchmarks for working out what constitutes a manageable caseload. Its findings may be helpful to other community-based services wishing to assess practitioners' workloads.
- The components on risk/vulnerability and coordination of care in the workload format worked well for most participants and these have remained unchanged. The components on time commitment and indirect professional demands were less well accepted and some alterations have been made.
- The pilot also highlighted the variability of caseloads among practitioners and of interpreting what constituted 'enhanced' or 'standard' care. These needed to be addressed and may also be pertinent to other community services.
This article has been double-blind peer-reviewed.