How do other professions deal with caseloads?

Social work is crying out for more effective caseload management. As the search for a standardised system continues, Mark Hunter looks at the lessons to be learned from other professions

(pictured: Helga Pile, BASW. She says traffic light approch could be of some use in social work caseload management)

How caseloads are managed in…

The probation service

A workload management tool was developed by the probation service in 2005. This allows probation officers to assess their workload, including a four-tiered weighting system to account for case complexity. The result is a traffic-light system in which the workload is judged to be red (working at 10% or more above capacity), amber (at full capacity or 10% above), green (95-100%) or blue (below 95%).

However, according to Harry Fletcher, assistant general secretary of probation officers’ union Napo, the tool is used with varying consistency across the country. “It’s entirely arbitrary whether management uses it or not. You can go to your manager and say ‘look I’m in the red zone’, but nothing happens. We’ve been campaigning for an effective caseload management tool for over eight years.”

Unison’s national officer for social workers, Helga Pile, believes the traffic-light approach would be a useful starting point for an early-warning system in social work. But she adds: “It will only work if employers are signed up to it and can be held to account. Any agreed system of measuring overload only takes you so far – there has to be some means of securing a response. Council social workers are employed by bodies with democratically accountable councillors – so instituting a public reporting system to show when caseloads are in the red could help bring pressure to bear.”

Psychiatry

The Royal College of Psychiatrists has implemented a number of initiatives to reduce caseloads from the days of the asylums when a consultant psychiatrist could typically have a caseload of over 400. Current caseload management relies on better case assessment and more effective use of the wide range of skills within multi-disciplinary teams.

“The most important thing is for caseloads to be regularly reviewed to ensure that the most unwell patients with the most complex needs can access services in a timely way and by professionals who can best meet their needs,” says Dr Shanaya Rathod, consultant psychiatrist and associate medical director at Hampshire Partnership NHS Foundation Trust.

Rathod says cases are not weighted by complexity but “clusters of symptoms” are identified to decide which patients have the most complex needs.

Case review and assessment should be important parts of any workload protection system, says Pile, “because we need to factor in risk and complexity in terms of work allocation, and in deciding in supervision which cases can wait when capacity is reached.”

But she warns that efforts to increase multi-disciplinary working can sometimes backfire, “leaving social workers carrying the load”.

Community nursing

Community nurses are not micro-managed to the same extent as the social care workforce and are therefore allowed to use their professional judgement to juggle their caseloads as they see fit. This leads to a reasonably effective but rather ad-hoc system of caseload management, says the Royal College of Nursing’s primary care adviser Lynne Young.

“You’ve got a great deal of professional autonomy as a community nurse, so for the most part you are just left to get on with it and you can judge for yourself which cases require the most attention. Referrals come from the GP or hospital, so you don’t have much control over how many you get. But you are not totally isolated, you are part of a team and there is support.”

Maggie Mellon, social work consultant, says: “I agree that we need more reliance on judgement and less on tick box procedures. However, there needs to be some measurement of effectiveness against which autonomy is judged. Accountability for decisions goes along with having the right training and expert knowledgeable support to make those decisions. At the moment, these are both in short supply in social work.”

Teaching

Probably the best example of a capped system is the 30-pupil limit on primary school classes. Simple to understand, universal and enforceable. But, as any teacher will tell you, it is quite possible for a poor class of 20 to create twice as much work as a good class of 30. Extrapolate this to social work and the system seems to have very little relevance at all, says the Tavistock Centre’s assistant director of education and training Carolyn Cousins. “Cases can be so different in terms of the hours they require, that you are comparing apples and oranges, really.”

Social work’s struggle for more manageable caseloads

The need for a radical overhaul of caseload management in social work appears to be universally acknowledged but debate continues to rage over which method should be used instead.

There is much speculation over the model or models that will be recommended by the Social Work Reform Board, currently drawing up plans to implement last year’s Social Work Task Force recommendations for a “whole-system approach” to workload management for the profession in England.

The difficulty of this task can be gauged from the wealth of opinions being expressed across social care’s media, message boards and blogosphere.

Social workers who took part in Community Care’s exclusive caseloads survey were firmly in favour of a cap on the maximum number of cases for an individual practitioner, with more than 90% subscribing to this view.

But a simple limit on caseloads was rejected by the Social Work Task Force and closer inspection of the comments in the Community Care poll suggests that even those in favour of a cap realise that this alone will not solve the crisis of overburdened frontline staff.

“It’s not just about the number of cases, but also the type of cases,” says one children’s social worker in response to the survey. “However, fewer cases would be a good starting point.”

“Caps on caseloads need to take into consideration more than just the numbers of children,” says another children’s worker. “The complexity of each child’s situation needs to be taken into account.”

Other respondents make the point that the amount of paperwork varies from case to case.

The debate has also raged on Community Care’s online CareSpace forum, where contributors have put the case for more temporary staff being available to cope with fluctuations in workload, increased professional responsibility for practitioners, and weighting cases for complexity.

Other bloggers have stressed the need for more effective supervision. Carolyn Cousins, assistant director of education and training at the Tavistock Centre, who has developed her own weighted system of caseload allocation, agrees that the relationship between managers and employees is crucial to achieving effective caseload management.

Roger Kline, social care spokesperson for trade union Aspect and member of the Social Work Reform Board, says board members have been looking at caseload management models from other professions, but they have realised that these can be difficult to translate into social work.

And the debate over which caseload management tool is best should not detract from the need for better management of practitioners’ time and expertise, according to social work consultant Maggie Mellon.

“The quality and effectiveness of the intervention should guide the focusing of resources. Systems that only prioritise and respond to high-end need can often neglect earlier intervention – the ‘stitch in time’ approach,” she says.

“The question we have to ask first is: ‘Are we using social workers properly and ensuring users receive a quality service?’ The question that is usually asked is ‘How many cases are allocated and how quickly’?”

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This article is published in the 7 October 2010 edition of Community Care magazine under the headline How Are Caseloads Managed Elsewhere?