Scottish Government

Working with young people: A profile of projects funded by the Partnership Drugs Initiative

Chapter 4: The Recruitment of Clients and the Management of Caseloads

This chapter describes the ways in which the projects recruited their clients and sought to manage their caseloads.

Inward referrals

The principal way in which the projects recruited their clients was through referrals received from other agencies. However, this was far from straightforward and the nature and quality of inward referrals proved to be troublesome for many of the projects. There were three issues here: low rates of referral, inappropriate referrals and late referrals.

Low rates of referral were a considerable problem for some of the projects, especially in the initial stages of their operation. The problem was that referrals did not occur automatically on the establishment of a project. The business had to be created by the project advertising its presence and purpose to prospective referrers. Some of the projects recognised that, in their early stages, they had not done enough to ensure an adequate supply of cases. An equally significant problem for some projects was referrals that were in a variety of ways inappropriate for their particular model of intervention. As with late referrals, this problem was related to the extent to which projects had been able to communicate clearly to other agencies the nature of their work and the sorts of cases which it was appropriate to send them. Sometimes other agencies were unclear about the nature of the project's eligibility criteria and, on other occasions, they simply did not have an adequate comprehension of its aims and parameters. For example, the Peterhead project experienced difficulties with other agencies who sometimes viewed its service as being similar to an adult drugs service, when in fact its practice and objectives were markedly different. In another instance, it was other agencies' restricted view of what constituted a drug problem that created difficulties for the project:

"I think the other kind of hindrance is that people see drugs problems as somebody that has a heroin problem. They don't realise that a young kid smoking hash or something, that's an issue. Or they're drinking heavily at the weekend, or, you know. These are all still issues that are there and that's where the preventative and the education side of it comes into it, and I think people still perceive it as, we have a heroin user, let's phone (name), you know. So, it's taken a while to break that down, and we're still in the process".

Projects which experienced referral deficits attempted to encourage referrals in a number of ways. The principal way of achieving this was through vigorous promotion of the service by means of intensive networking and campaigns specifically targeted at increasing referrals. In an attempt to boost their referrals and broaden their intake base the Reiver project launched a campaign which targeted all levels of a relevant organisation - for instance, nurses as well as doctors at a Health Centre - with the intention that awareness of the service offered by the project would spread upwards as well as downwards. Contacts established in this way were also subsequently maintained and refreshed regularly. The Peterhead team appeared to work particularly hard at promoting their service. The project manager and the workers regularly engaged in promotional activities which included extensive networking with statutory agencies. Teachers around Aberdeenshire, especially in guidance departments, were targeted with packs produced by project staff and referrals were also actively sought through the ADAT education subgroup. 'Roadshows' to promote the project's services were also being launched and staff were arranging presentations for GP surgery personnel. The Inverclyde project had introduced a system of telephone referrals to make self-referral by young people easier. All of the projects which had used them reported that these activities had had the desired effect and that referral rates had improved considerably as a result of them. Project managers also emphasised that the attempt to promote their service and ensure an adequate supply of referrals could not be a one off activity but was something that had to be sustained.

Projects also sought to enhance the appropriateness of the referrals they received by improving and clarifying their criteria for referral and by attempting to ensure, by means of the sorts of intensive promotional activities described above, that these were fully understood. In some cases this involved adapting the referral form to make the criteria clearer. For example, the referral form used by the Connect project is very detailed. It gathers contact and personal details on the young person and the referrer as well as details of the concerns or issues leading to the referral. The form creates a substance user profile, with a matrix of drug types by stages of use (experimental to frequent) to be ticked. It also asks why the use is problematic, whether the young person is injecting and what their preferred substance is. To be accepted onto the project, those referred must be within the target age range, have been clearly identified as having problematic substance use, be aware of the referral and be willing to engage with the programme.

Another difficulty encountered by some of the projects was the problem of late referrals; that is to say, referrals which occurred at too late a stage in a client's career to be entirely appropriate to the aims and models of intervention offered by a project. These referrals tended to undermine the project's original concept and intention. In particular, project workers complained that cases were frequently referred to them too late for them to pursue their preventive agenda properly.

Several of the projects reported that they tended to get called in at a stage at which young people or families were struggling with addictive behaviours which were already well established and which were having a considerably adverse effect on the lives of those involved. For instance, Families First, although preventive in concept, received most of its cases when they were at a critical stage. This meant that a service which was originally conceived as operating in a largely preventative capacity, found itself dealing in the main with families in crisis. Examples referred to by staff in this project included families going through relationship crises, children living in an atmosphere of violence, or situations in which unsafe adults were coming and going in the house. Social work referrals, in particular, it was claimed were likely to be made at a time of crisis. However, late referrals were not confined to social work and two project managers reported that schools also tended to refer on the point of crisis.

As with the other two referral problems, projects attempted to address this issue in several ways. Part of their effort was devoted to 'educating' potential referrers on the stage at which clients should be referred to the project as part of their general promotional and networking activities. However, a number of the projects also took steps to establish alternative referral routes as a way of trying to increase the volume of appropriate referrals. In particular, several of the projects were making a determined effort to recruit from sources other than social work and to try to broaden the base of their referrals to include families or young people who were not in contact with services. For example, the East Ayrshire project was trying to address this issue by seeking funding to employ an additional young carers' worker, who would be based in a local health centre, in the hope that this outreach role might make it easier for the project to access young carers at an earlier stage. Families First prepared materials for distribution in GPs' surgeries, family centres and community centres in an attempt to recruit more hard-to-reach families. The Peterhead team was endeavouring to recruit young people not known to services by a variety of means in order to promote early intervention and reach a wider client base:

"But what we are trying to concentrate on now is trying to target your normal everyday young folk who don't have social workers and aren't known to the social services. So we are trying to concentrate on doctor's surgeries and all the different places for posters and stuff. Some schools put out our flyers in the young people's report cards and things like that because that targets heaps of young people at once. These aren't young people who will necessarily be known by social services because there are hundreds of young people that take drugs every day and they might never come to anyone's attention. It doesn't mean to say that they don't need to know all the information any less than the people who have got social work input".

Reaching and retaining clients

In spite of their efforts to optimise referral and recruitment, all of the projects were aware that there were a significant number of potential clients who were very difficult to reach. These 'hard to reach' cases could be a source of considerable frustration for project workers. As we saw, several projects tried to address this issue through the use of outreach work, by attempting to broaden their referral base or by seeking to encourage self-referral.

Territorialism could also make recruitment difficult by making access to a project highly problematic for young people. In many communities it was unacceptable and frequently dangerous, for them to attempt to attend a service outwith their own immediate area:

"The territorialism thing is really bad because a lot of kids can't even travel on a bus through a certain area because they'll be recognised and their bus will get stoned. Boys will stop the bus, jump on, and give them a battering basically".

This meant that a project with a fixed base could find it difficult to recruit young people from outside its territorial borders. It also meant that the movement of staff between areas or territories was to be avoided as far as possible:

"Staff that are assigned to the geographical areas, they'll get to know the staff in that area…They can't swap areas too much because if they swap areas too much, the young people don't take to it because of the territorial issues and the rest of it, and the building of relationships. It really has to be the same people in the same areas".

The most common solutions adopted to address this issue were either to establish several different locations in which the project could engage with clients or to undertake outreach work. The West Lothian project's use of a mobile base in the form of a bus provided a novel way of getting round the problem.

While reaching clients could be difficult, retaining them could also be problematic. Most projects experienced the frustration of missed appointments and clients dropping out of their programme before their intervention had been completed. To some extent, this was seen as coming with the territory and there was particular resignation among project workers as far as the non-retention of complex or chronic cases was concerned. Nevertheless, project staff did make considerable efforts to retain clients. Some tried to make their meeting spaces as client friendly as possible and to avoid settings which had statutory or stigmatising connotations. Others sought to encourage retention through the adoption of approaches to intervention that were client-centred and non-directive.

In terms of their ability to recruit and retain clients, many projects saw the fact that they were non-statutory organisations as being of considerable advantage. They believed that this enhanced their acceptability among their various client groups, many of whom were perceived as being suspicious of statutory services and resistant to becoming involved with them:

"I was 25 years in Social Work, so I know the - I don't have a problem with it, but I see the value of this sector. It's the flexibility. And it's also that people will more happily access services in the voluntary sector. Particularly when there's something happening with children. They'll do it and not be so scared".

"I think our biggest strength is that we are non-statutory and we listen. That is the feedback that we get. They don't have to go to Social Work to come and see us and that is our big strength".

Coping with demand

Not surprisingly perhaps, nearly all of the projects claimed that their resources were inadequate to meet the demand for their services. Some felt that their service required additional staff while others complained of a lack of administrative support. Mostly the problem was a consequence of the high demand for the service and a consciousness on the part of project workers that it was impossible to meet it. In some of the projects this had already resulted in the emergence of waiting lists or in the introduction of a reduced service. Most of the other projects were having to give serious consideration to the introduction of similar measures.

Waiting lists were viewed negatively by project staff but seen by most as being inevitable. Some projects were reluctantly having to consider reducing the service they provided, sometimes as a way of obviating the need for waiting lists. This could mean seeing clients less frequently, substituting group work for more intensive one-to-one interviews, making adjustments to the project's referral criteria or, in one case, guaranteeing only initial screening and assessment while the referral rate was high.

Rural projects experienced an additional problem in meeting the need for their services. The geographic spread of their cases meant that travel consumed a lot of the project workers' time. Some of the rural projects covered very large areas. For instance, the Highland Mentoring scheme covers the entire Highland region. The demands imposed by geography were placing severe restrictions on some rural projects' ability to fulfil their role adequately. Some sought to address the problem by undertaking as many contacts as possible when in an area while others tried to increase the amount of work undertaken on each visit.