VOL: 103, ISSUE: 16, PAGE NO: 32-33
Martin McGuinness, RMN, RGN, DMS, LLB, MSc; Tony Leiba, PhD, RMN, RNT; Caroline Mathiason, LCSLT, MBA
Martin McGuinness is registered manager, Astracare (UK) Ltd; Tony Leiba, is chair 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 is project manager/care consultant, North East London Mental Health Trust and Goodmayes Hospital, Ilford, Essex.
Abstract: McGuinness, M. et al (2007) Worload weighting in community mental health teams. nursingtimes.net
Aim: To establish whether the workload weighting system is a reliable way to assess the workload of community mental health teams.
Method: Teams were trained in the use of a tool developed by managers at North East London Mental Health Trust, which was then adapted slightly. A questionnaire survey was carried out and evaluated.
Results: Eleven teams were involved, with a total of 93 staff members trained in the use of the workload weighting system. The study response rate was 66%. The results reflect in the main the views of community mental health nurses, who made up over half of the team members. Caseloads varied widely among the teams with an average of 25 cases per team; further exploration is needed to understand why this variation exists and what effect this may have for staff and the services in general.
Discussion: The training provided was regarded as good and staff felt it enhanced their understanding of the process and scoring of the system. The system was judged to be very good for the sections on risk/vulnerability and coordinating care, with some improvement needed on the time-commitment section. Indirect professional demand proved the most contentious section with many issues raised and areas to be addressed.
Conclusion: Overall the system was found to be useful and beneficial, and a good indicator of a manageable caseload for a community mental health team worker. A revised format based on the findings has been produced.
Since their inception over the last two decades, community mental health teams (CMHTs) have operated in an environment where some trust operational managers express concerns over lack of guidance on how to manage their growing role and responsibilities. The National Service Framework for Mental Health (DH, 1999) outlined the possible make-up of teams and their role in general terms as well as detailing some numerical benchmarks for caseloads but left it very much to local mental health trusts to develop working practices.
A workload weighting system had been developed by a group of CMHT managers at North East London Mental Health Trust over a number of years to help teams manage their total workloads. This was adopted haphazardly in some CMHTs across NELMHT. This pilot builds on that original work.
There are considerable pressures on CMHTs as they strive to meet the needs of clients with mental illness and deliver the standards set by the Department of Health (1999). These pressures may also be increased by the reduction in psychiatric beds available.
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. Caseloads are an important parameter for professionals in mental health services because there is a limit to the number of people who can be looked after effectively and safely at any one time. This is now formally recognised: the NSF for mental health (DH, 1999) stated that workforce planning would be carried out to estimate the numbers needed in 2002 and 2005 for each professional discipline in mental health.
The attempts to define a benchmark for effective manageable caseloads in terms of numerical quantities have been based on levels of demand within these numbers. For those practising assertive community treatment (ACT) the specific requirement of no fewer than eight and no more than 12 cases per worker has been formulated (Stein and De Santos, 1998). Tyrer (2001) concluded that it seems likely that an average target of 20 patients per caseload, with approximately half having severe mental illness, is a reasonable expectation for community services. The DH (2002) indicated the size of the caseload that each CMHT worker should manage: ity stipulated that full-time care coordinators are to have a maximum caseload of 35 but this figure would clearly require modification in light of such factors as complexity of need.
A system of caseload weighting was developed within a former community trust (Barking, Havering and Brentwood Community Health Care NHS Trust) in Essex in 1997. This system attempted to provide a benchmark for effective manageable caseloads for CMHT workers and was one of a range of mechanisms to ensure that demands on a practitioner’s time were manageable, enabling them to provide a high-quality service. It consisted of four key demand indicators that were thought to represent demand on allocated workers:
- Level of risk/vulnerability;
- Care coordinating;
- Time commitment;
- Indirect professional demand/additional responsibilities.
This system had been tested and reviewed anecdotally in the field for three years.
The formation of NELMHT prompted the need to review community mental health services across the trust. Team managers highlighted some issues related to the workload weighting system that had been adopted inconsistently in some boroughs across the new trust. There was no conformity, no structured training of staff and no evaluation of its use. The trust board wanted to see the system used more consistently. As a first step it needed to be validated.
A manual and electronic search was carried out, using the following search terms: caseload management and teams and mental and health and community. Database(s) used were: BNI Plus, Cochrane June 2004 Edition, RCN Journals database (1985-1996), CINAHL database 2003/10-2004/05HMIC, DH-Data and Kings Fund database 2004/05 and Silver Platter MEDLINE (1976-2002).
The literature revealed that there was little evidence to suggest much work had been done on defining manageable caseloads in the community, beyond pure numbers with different levels of demand within the total number (Stein and De Santos, 1998; Tyrer, 2001).
Marshall et al (2004) compared case management with standard care in the community. Intensive case management emphasises the importance of small caseloads and high-intensity input. The study does not address the issue of defining a manageable caseload.
Drennan (1990) devised a system for profiling and comparing district nurse workloads through weighting the stress factors involved to help decisions about staff resource allocations. Thomas (1995) found that the work of district nursing and health visiting has conventionally been assessed using the Korner method, which has been criticised for its narrow task-based approach that relies on face-to-face contacts and annual caseload counts rather than the scope and content of nursing work; this could equally apply to the work of CMHT staff.
Onyett (2003) described a caseload-weighting scheme developed at North Dorset PCT, drawing on a framework of client definitions and using a simple three-point weighting scale. This scheme was not intended to be definitive about a manageable caseload but could highlight inequalities in the work being undertaken by team members.
The aim was to find out if the format of the tool in use at that time was a reliable way to assess the workload of community mental health professionals.
A steering group was established and facilitated by a project manager. It consisted of interested and experienced managers and practitioners and was guided by the trust’s research fellow. Its role was to take responsibility for the details of the research, questionnaires, interviews, training and documentation. The caseload weighting system (Box 1) already in use was adapted slightly and guidelines for its use were strengthened. A project proposal was developed and a reference group of user and carer groups was established and consulted before the pilot was implemented.
Box1. Summary of the workload weighting tool
Workload weighting is a mechanism to ensure that the demands on a practitioner’s time are manageable to the extent that they can deliver a high-quality service. Other aspects include:
Points are allocated for agreed key elements or indicators which are thought to represent demand upon allocated workers. Three main indicators of demand are used:
An additional element takes account of practitioners’ indirect professional responsibilities.
Every open, allocated case in a worker’s caseload is scored against each of the first three indicators on a scale of 0-5 for risk/vulnerability, 1-5 for care co-ordination and 1-10 for time commitment. Each worker should carry a workload totalling about 225 case-weighting points unless an individual’s job involves numerous additional responsibilities. In such cases they are given a reduced workload weighting capacity.
The workload weighting system is a benchmark for safe working practice and not a definitive ceiling.
Briefing papers were compiled explaining the project and giving the background to the development of the tool; these were circulated among the teams and to the reference group.
As the pilot aimed to review and improve services, the following ethical issues were addressed:
- All staff received full information and gave their agreement to participate;
- There was agreement and participation of the senior managers of the different professional;
- Staff were required to identify their profession but not state their name, thereby achieving some anonymity.
The pilot was undertaken with 11 of the 21 CMHTs within the trust - all participating teams volunteered themselves. The teams were trained in the use of the tool. Eight trainers from the steering group, managers and practitioners in the pilot teams underwent a briefing session to ensure they were confident in using and scoring the tool and to ensure consistency.
Each trainer undertook the training of approximately two teams and for each team there were two trainers plus the project manager who attended all the sessions (apart from one) to ensure consistency.
Trainers visited each team at their base and the whole team was invited to attend the training session, including supervisors and those being supervised. The session lasted approximately one-and-a-half to two hours. Documentation was sent before the training day and colleagues were asked to familiarise themselves with the content. There was an opportunity for team members to identify issues and discuss these with the trainers in an open forum during the training session. The session included:
- Familiarisation with documentation and the system itself;
- Information giving, including explanation of the questionnaire that was to follow;
- Group work, which took the form of scenario-planning with a case study, problem-solving and scoring the study;
- Details of how the tool should be scored and applied during supervision.
Supervisors (team managers and team leaders) were asked to see each member of their team after training to discuss their caseload in the manner outlined above. Once practitioners had done their first workload weighting supervision session, they were given a questionnaire, to be returned to the team manager within five working days. Team managers returned the completed questionnaires to the project manager.
Comments from all the training sessions, and information and comments from the questionnaires were then analysed.
The findings relate to the staff responses to the questionnaire. This had five sections (general information, risk and vulnerability, coordinating care, time commitment, indirect professional demand), which are presented separately with related analysis and discussion.
Of the 93 possible respondents, 61 returned completed questionnaires. A higher response was expected, considering that all staff sent the questionnaire were employed by the trust. Some teams were keen to complete the questionnaires, while others felt the whole process was ‘cumbersome and time-consuming’.
Nurses outnumbered all other professionals in completing questionnaires (Fig 1). The findings therefore include a large proportion of nurses’ views. Indeed, some participants believed that the tool ‘does not take account of therapies’, and that it targets mainly community nurses.
The average number of clients on a respondent’s caseload was 25 (range 12-43) (Fig 2). The great disparity between the highest and the lowest caseloads has implications for staff and services and warrants further investigation.
The answers to questions exploring the training on how to use the workload weighting system indicated staff clearly understood all aspects of its processes and scoring method - 98% said they fully understood how to use the system. Negative comments included ‘difficulty in scoring joint working’ and ‘scoring might not reflect crisis work adequately’, while positive comments included ‘guidance useful in describing risk/vulnerability/harm to self’ and ‘system useful in scoring care coordination; easy to follow’.
Risk and vulnerability
All the questions pertaining to the accuracy of the risk and vulnerability section received 79-89% agreement. The respondents with reservations about the scoring system made the following comments:
‘Sometimes due to client reluctance to engage it can be difficult to assess their vulnerability.’
‘Could have categories of clients who have never had deliberate self-harm issues as the same category as those who have a history of deliberate self-harm but no intentions currently.’
‘No clear instructions on balancing act between history and current presentation - what are the parameters? When does history end?’
‘Risk/vulnerability not helpful in relation to harm to others, forensic term used unwisely, people may have committed ABH/GBH but not charged, therefore no forensic history.’
There was agreement that this section of the weighting system reflected the process for recognising and scoring the coordination of care. All questions in this section were answered with 70-80% positive agreement.
The findings show that 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 may require. This reflects what is common throughout the teams, namely that there are differences from one team to another in what team members categorise as ‘enhanced’ or ‘standard’ care. This will need further investigation if consistency is to be achieved.
Generally the respondents were in agreement that this 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 from staff and managers. While time commitment focuses on face-to-face or telephone contacts, most of the comments relate to indirect contact with clients that is not recorded elsewhere in the tool. The comments included such things as travel time not being included; time spent in dealing with other agencies not accounted for; indirect work with clients, for example, report writing, form filling, other administrative duties, abortive visits and attending panel meetings; no account is taken of group work, planning and preparing before a group takes place; and evaluation and cover for colleagues and rotas.
Indirect professional demand
Asked whether the areas of indirect professional demand identified 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. One respondent said ‘this section is confusing’ and another noted that it ‘needs revising, it does not take account of many areas’. Further comments specified some of those areas that were not included:
‘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.’
‘Ad hoc meetings and business/team meetings not included.’
‘Short-term courses, one-off workshops, informal team supervision, induction of new staff not accounted for.’
There was a consensus among half of the respondents that this section needs revision.
Overall effectiveness of the workload weighting system
The positive scores ranged from 41-77% and negative scores from 15-59%. Generally staff from some professions - such as therapists and psychologists - felt that the scoring system was not gauged correctly and that the tool 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.’
Many staff indicated that some duties were not reflected in the scoring system.
The staff offered what they considered to be the strengths of the system:
‘Is a structured way of looking at workloads.’
‘System has potential but still requires work.’
‘Guidance useful in describing risk and vulnerability/care co-ordination.’
‘It is straightforward and clear.’
‘Valuable in the process of assessment and review of needs.’
Some staff suggested areas for improvement:
‘Revisit the scoring system for all staff.’
‘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.’
‘Revisit ASW issue as great variation exists across the trust.’
‘Explore differences associated with criteria for standard/enhanced Care Programme Approach (CPA).’
‘Revisit some of the sections to ensure that therapy work is reflected.’
Summary of the findings
Caseloads varied widely among the teams (range 12-45; average 25). 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 process and scoring of the system. However, some comments in the questionnaire indicated that some sections of the system need to be revisited in the training to ensure they are fully understood and interpreted correctly.
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.
Limitations of the study
A reasonable number of staff members participated in the study, although it was anticipated that a higher number would have been involved. We thought more would take part as they worked for the trust in CMHTs that were under increasing pressure to meet higher demands of them, and this system was a potential way of indicating to management when capacity to meet demands was being exceeded.
Community nurses made up more than half of those who responded. It was hoped that there might have been a higher percentage of other professionals returning questionnaires.
Overall the system proved to be useful and beneficial; it was also shown to be a useful format for supervision and indicator of what is a manageable caseload for individual CMHT workers, although some elements required revision.
The system as used in the study is just one mechanism in a range that might be used to measure practitioners’ workloads. It was not designed as an all-embracing process that would look at all aspects of a practitioner’s work; if this were the case it would be much more detailed, would take longer to administer and would not be practical for busy CMHTs. The recommendations below were made bearing this in mind:
- The steering group should consider the issues raised and the suggested improvements made by staff through the training process and questionnaire, and make a considered judgement about which suggestions are incorporated into a revised system;
- Using the revised scoring system, a programme of training and implementation across CMHTs in the trust should be rolled out;
- 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 met to consider the study findings and recommendations and agreed to the following:
- Regarding sections on time commitment and indirect professional demand, it was felt that extending time commitment beyond direct and telephone contact with clients would make the system too complicated and unworkable;
- Within indirect professional demand it was agreed to include administrative meetings, that is, team allocation and business meetings;
- It was felt that the issue of training was already adequately provided for and that any extension of this would be complicated and impractical;
- Receiving supervision was to be included as indirect professional demand in addition to giving supervision;
- It was felt that, 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.
A subsequent audit of the use of the system across three CMHTs six months later found that social work and community mental health nurse disciplines were almost the exclusive users of the workload weighting system.
This study examined a system to measure the workload of CMHTs in a mental health trust in East London. It enabled the trust to understand the components that make up the work of CMHT workers and offers benchmarks for working out what constitutes a manageable caseload. It is clear that there is a lack of published material on workload weighting for CMHTs, and this heightened the need for the trust to verify and authenticate what was happening in some of the teams.
The pilot has shown that three of the four components in the workload format worked well for most participants and these have remained unchanged. The other two components were less well-accepted by participants and some alterations have been made based on suggestions of staff members.
The pilot has also highlighted additional issues that will be included in future reviews of CMHTs:
- Variability of caseloads among the teams;
- Variability in the interpretation of standard and enhanced CPA.
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