Caseload Management for CMHNs

Author: Ruth Dube
Edited by Jo Davis

The closure of psychiatric hospitals, an increased number of vulnerable people with severe mental illness living in the community and several high profile homicide inquiries has kept mental health services high on the public agenda.

A succession of policy and legislative changes have been introduced by the Government in order to address these issues, most recently Modernising Mental Health Services - Safe, Sound and Supportive (Department of Health 1998). Whilst some of the changes in legislation have been welcomed, such as the introduction of the Care Programme Approach (CPA), (Department of Health 1990), at time inadequate resources have not enable consistent and effective implementation. Community Psychiatric Nurses (CPNs) have been at the forefront of many of these changes and as a result some have experienced rising caseloads presenting various management problems and sometimes unacceptable levels for safe practice.

The report Mental Health Care - From Problems to Solutions (NAHAT 1997) indicated that from the trusts interviewed, CPNs’ caseloads ranged from between 10 to 25 to more than 70. The numbers nearer to the latter figure may indeed reflect the common experience of many CPNs. The report suggested that if CPNs are to provide adequate support for the severely mentally ill, caseloads should range from under 10, where there are few other services to access, up to 25, where the clients are engaged with residential or day care service. The report made it clear that caseloads in excess of 45 could not possibly provide the quality of service required. Clearly, if practitioners have caseloads of such proportions, they may be unable to provide anything more than a very basic service.

The fourth Quinquennial National Community Mental Health Nursing Census (Brooker and White 1997) reports that the number of clients on the CPNs’ caseloads with severe mental illness had increased by 85%. From 1990 to 1996 there had been a 10% increase in the average caseload size in England and Wales. The percentage change also shows considerable variation when presented by regional office catchment area.

The essential focus of CPN practice is working with people with severe mental illnesses. CPNs have a central role in the delivery of care for the severely mentally ill under the CPA and other significant related legislation. They can no longer continue absorbing all the work that comes their way as they will at risk of burnout (Grevatt H 1993), suffer stress and increased sickness levels. In order to continue providing safe and effective care CPNs must take a proactive approach in managing caseloads. This article identifies and discusses some key factors and offers guidance to assist members in ensuring they maintain good and safe clinical practice.

KEY FACTORS
Service Organisation
The NHS changes within the past few years have created pressures for mental health service organisation. The implementation of the CPA has highlighted significant variations in local service provision. Changes in management structures of CPN services have left some CPNs often on lower grades, feeling isolated, vulnerable to demands made by referrers and in danger of being made scapegoats for inadequately managed and resourced services. Caseloads and caseload management are essential components of effective service delivery, therefore organisations and service managers have a responsibility to construct clear local strategies, develop and maintain a framework for good practice.

There needs to be clear job descriptions, indicating key areas of responsibility. CPNs need to actively participate in the development of local protocols through collaborative working with service managers.

Clinical Supervision
The Mental Health Nursing Review (DOH 1994) recommended that clinical supervision (Butterworth & Faugier 1992) is established as an integral part of clinical practice up to and including the level of advanced practitioner. The UKCC (UKCC 1996) states that all nurses should have access to clinical supervision. Clinical Supervision (Wilkin P. 1997) therefore should be incorporated into service organisation planning to ensure that supervisors are identified and allocated for all clinicians.

All CPNs should assertively request adequate and regular supervision from appropriately skilled supervision. Clinical supervision should provide opportunities to critically examine clinical situations which impact on aspects of caseload management.

Caseload Numbers and Composition
Often CPNs seek guidance about recommended caseload numbers, although numbers alone may not accurately reflect the actual workload. The composition or casemix of a caseload should always be taken into consideration. Assessment and acceptance for CPA is based on the complexity and severity of each individual patient’s/user’s needs and this must reflect in agreed service standards and protocols for CPNs’ caseloads. The calculation of an acceptable number ranging from 10 to 45 must therefore take into account CPA levels and significant legislation and the availability of appropriate service resources.

CPNs need to be assertive in discussions with service managers to ensure that all aspects of their caseloads are regularly monitored and reviewed. CPNs who are keyworkers for people with severe mental illness should be acknowledged as case managers (Shepherd G. 1990) which will reflect the size of caseloads, primary responsibility and the use of more sophisticated methods of monitoring.

Working in Partnership
The involvement of patients/users and their carers is a key component of the CPA. The Mental Health Nursing Review, The Sainsbury Centre Report - Pulling together (Sainsbury Centre for Mental Health 1996) and more recent the Government’s Modernising Mental Health Services - Safe, Sound and Supportive all highlight that patients/users and their carers should play an active part in the process of treatment and care. the patients/users and carers are themselves demanding to be more involved.

CPNs working in collaboration with patients/users, carers and other agencies should ensure that care plans reflect the individuals’ needs and not the convenience of the service.
CPNs need to maintain their established relationships with patients/users and carers and this requires manageable caseloads which can accommodate this aspect of clinical practice.

Referrals
There are many variations in how referrals are received and managed by mental health services, dependent on the organisation of each team. In some services referrals are received by the Community Mental Health Team (CMHT) and then allocated to the appropriate clinician. In other services referrals are made to individual members of the team whilst a combination of the two is practised in some services. Whatever system is in place, all CMHTs should have referral policies which are clearly communicated with referring agencies.

CPNs need to have a clear understanding of their local referral systems. There needs to be particular support from managers and clinical supervisors for those not working in CMHTs, who can feel isolated and pressurised by referrers. CPNs need to be more assertive in saying NO in inappropriate referrals as specified in local referral policies.

Assessment
The key component of the CPA is systematic arrangement for assessment of health and social care needs of all people referred to the mental health services. CPNs will be involved in assessment of those accepted by the service which should not necessarily mean acceptance onto their caseload. The outcome of the assessment which would determine the level of CPA should also determine:-

Eligibility for CPN caseload or other CMHT team member
Any issues concerning safety if accepted onto caseload.
Referral to other agencies.
CPNs expected to be keyworkers must not accept people following assessment if it means an inappropriate increase in size of caseload. There should be support from managers and clinical supervisors to ensure that this does not happen.

Waiting Lists
Waiting lists are becoming increasingly common on CPN practice and should be a necessary component of local service provision.
CPNs and service managers should ensure that local protocols are in place which specifiy the waiting list criteria.
Waiting list protocols should be effectively communicated to referrers through appropriate mechanisms and not left to individual CPNs.

Discharge
Excessive numbers on caseloads may pften be a result of inadequate resources, lack of support and ineffective monitoring (Lelliot P. 1996) of work and caseloads putting pressure on practitioners to retain people who could otherwise be discharged.

Regular clinical supervision and reviews in multidisciplinary team meetings should ensurre adequate monitoring of work and caseloads which would address these shortfalls.
Services need to prioritise resources to ensure that they are available for the most vulnerable who could easily slip through the net.
CPNs should have access to information of all local services which can be utilised by patients/users.

Time Management
There has been pressure on CPNs not only to cope with excessive caseloads, but increased face-to-face contact, making it increasingly difficult to allocate time for other crucial activities and essential components of clinical practice. Planning work and managing caseloads must take into account activities and functions such as:-

Record Keeping
Travel
Telephone Contacts
Meetings
Clinical Supervision
Liaison
Professional Development
Education, Teaching, mentoring
Personal Needs

Training
Access to training at all levels for mental health nurses remains a concern. Introduction and implementation of legislation has not been preceded by adequate training, courses and study days to enhance practitioner skills. Such training remains inaccessible to many CPNs.

Access to appropriate training should be made available to all CPNs to improve skills and enable effective practice.
There is a need for more specific training to develop skills in caseload management. Training and support to acquire knowledge and skills in audit, research and evidence based practice.

Accountability
Accountability (UKCC 1998) is an integral part of practice. The UKCC Code of Professional Conduct (1992) states that “as a registered nurse, midwife or health visitor you are personally accountable for your practice”. CPNs need to remember when managing their caseloads and practice to “act always in such a manner as to promote and safeguard the interests and wellbeing of patients and clients”.

CPNs should refer to the Code of Conduct when identifying their concerns to service managers and Trusts about reducing caseloads, to ensure safe levels of practice.
CPNs should seize opportunity to develop innovative practice, following examples of good practice such as that described by Salford NHS Trust CPNs (McNelly P & Co. 1998) and other good practice initiatives.

Conclusion
This members’ handbook insert aims to provide guidelines and framework for good practice. CPNA members are advised to seek further information from the literature referred to and beyond, and also to request training in caseload management. They should take responsibility in brining to managers’ attention key factors in caseload management and to actively get involved in discussing what actions need to be taken to ensure safe and effective delivery of care. members who experience difficulties in pursuing this should seek advise and support form their local MSF representatives. The CPNA and MSF are committed to supporting members in their activities to further develop and maintain good standards of care and practice.

References
Department of Health (1998). Modernising Mental Health Services - Safe and Supportive.
NAHAt (1997)Mental Health Care, from Problems to Solutions: An NHS Perspective.
Department of Health (1990). The Care Programme Approach for people with a mental illness referred to the specialist psychiatrist services. HC(90)23/LASSL(90)H.
Brooker C, White E. (1997). The Fourth Quinquennial National Community Mental Health Nursing Census for England and Wales.
Grevatt H. (1993) Avoiding burnout - Community Psychiatric Nursing Journal October 6.9.
Department of Health (1994) Working in Poartnership: A Collaborative approach to care.
Butterworth T, Faugier J (1992). Clinical Supervision and Mentorship in Nursing.
UKCC (1996). Position paper on clinical supervision for nursing and health visiting.
Wilkin P. (1998). Clinical supervision; The Rochdale support and development model.
Shepherd G. (1990). Case Management - Health Trends Vol. 22 No. 2.
Sainsbury Centre for Mental Health (1997). Pulling Together - the future roles and training of mental health staff.
Lelliot P. (1996). An Audit Pack for Monitoring the Care Programme Approach.
UKCC (1998). Guidelines for mental health and learning disabilities nursing.
UKCC (1992). The Code of Professional Conduct for the Nurse, Midwife and Health Visitor.
McNelly P, Prince E, Dicken A, McEvoy P (1998). “How Big is Your Caseload?”: an analysis of CPN workload. Mental Health Nursing, Vol 18, 2, pp10-12, CPN Publications, Bristol