Independant advocates and the Mental Capacity Act

On the eve of a roll out of a national advocacy service for vulnerable people, Derren Hayes looks back at the development of the service and asks whether it will be up to the task

The creation of the first statutory national advocacy service in the Mental Capacity Act 2005 was hailed as a groundbreaking development for the rights of vulnerable adults.

The act created the independent mental capacity advocate (Imca) service to help and support people who lack capacity and have no family or friends make important decisions about serious medical treatment and changes in residence.

Local authorities and NHS trusts will be required when making these decisions to appoint an Imca to represent the individual if there is no one else to support them. The Imca’s advice must be taken into account in the decision. An advocate is appointed to the person to voice their wishes, feelings, beliefs and values who will challenge decisions by agencies not in accordance with these.

Imca is to be rolled out nationally from April. Local authorities and health bodies have now commissioned services from the voluntary sector drawing on the experiences of the seven pilots that have been testing the best ways of working since January last year.

Community Care spoke to two of the pilots about what they had learned. Both found there was a lack of awareness among agencies that could refer clients about Imca and the 2005 act. Anna Murphy, Imca manager at Advocacy Matters in Cheshire, explains: “The general understanding isn’t very good. We spent a lot of time filtering out inappropriate referrals.”

A referral should only be made when a decision is needed imminently. There are four main client groups that advocates work with: people with dementia, mental health problems, learning difficulties and those who have had strokes or acquired a brain injury.

Murphy says a lot of time was spent visiting health and social care organisations to raise awareness of the service. “We targeted a lot of different professionals including community nurses, social workers, service managers of community mental health teams, discharge planning groups, hospital consultants and GPs. We explained what it is and how to refer.”

Vicky Cowin (pictured), an Imca at Cambridge House Advocacy in Camberwell, London, says that despite an enthusiastic response to the awareness-raising sessions “it initially took a while to get referrals”.

The better understanding of advocacy from the social care sector has meant most of her referrals have come from social workers. “Social services are more positive about advocates than other areas like mental health teams. Even though they had advocates working with them they still misunderstood the role.”

But Murphy’s experience has been different. Advocacy Matters already had strong relationships with health organisations and as a result has received 25 referrals from the NHS, a quarter of the total health referrals across the seven pilots.

“We’re a well-established regional organisation and are based in the same building as several NHS bodies. Imca was just an extension of that,” Murphy says.

The government extended the amount of funding for Imca so that pilots could spend an average of eight hours of advocacy a client – the original fund was for four hours a client – but there is concern that this is still inadequate.

Her manager Jenny Clark was at first concerned about whether Imca funding would stretch far enough to meet the needs of all those eligible for advocacy. In December 2006 funding for Imca was uncertain, but now local authorities will be agreeing contracts with advocacy providers in each area.

Clark had been concerned that the level of demand for the service was unclear: “It raises the question of who gets an Imca and who doesn’t? Which one do you choose to work with first? Maybe we’ll have to prioritise an adult protection issue over a change of residency case. My concern is there won’t be a consistent approach and we could do with guidance on that,” she says.

Clark was also concerned that Imca delivery could be dominated by the large national voluntary organisations that would provide services across all areas at the expense of smaller local ones that specialise in one or more of the client groups. “It worries me that a lot of the specialist organisations across the four client groups could be swallowed up. We need to find ways of supporting the smaller local organisations to fill these roles. Local organisations may go into partnership with national ones.”

For Richard Kramer, policy director at Turning Point, the availability of advocacy organisations to deliver Imca will be a big issue for commissioners in some areas.

“How do you commission an Imca service when there is no independent advocacy organisation in the area?

“In some areas commissioners may want to look at partnerships with organisations outside the area and deliver Imca across councils and NHS trusts. Commissioners tend to look at what’s already out there whereas Imca is meant to be in addition to existing services,” Kramer says.

Murphy believes the biggest challenge for Imcas when they go live will be retaining their independence from the pressure to do things in the way social services or primary care trusts want them to.

She says a clear management and support structure in place can help prevent against this. “It is very important Imca advocates keep their distance from social workers and nurses as they are separate from those teams. It is vital they have adequate supervision and support from managers and training development because it is a very different role to normal advocacy.”

Since contributing to this article Jenny Clark has moved to a post abroad.

Case Study
Vicky Cowin had been working as an advocate in Camberwell, south London, for more than two years before she was seconded to its Imca pilot. She explains the role’s requirements: “We may receive a referral about someone with dementia. A decision needs to be made as to whether the person should go into a nursing home or back to their own home. It’s my job to ensure that all the options have been looked at and that any decisions are made in the best interests of the client.

“People communicate in different ways – through communication aids and picture books. Sometimes you might find out whether a person wants to go into a nursing home by taking them there and seeing what their response is. I also talk to their care staff.

“People are moved from hospitals very quickly so you have to keep track of everything because you tend not to be kept up to date with developments. You also have to know the limitations of the role: it is about supporting the person to make the decision – anything else should be passed onto another advocate.

“You are able to read parts of patient notes that are relevant to the decision. The historical information also helps you understand what a person’s views were before they lost capacity. It can help identify any unresolved issues.

“Sometimes results can be quite limited: a very good one might be supporting a person to return to their own home, whereas a smaller one could be just ensuring they are informed and kept in the decision-making process even if they don’t return home. The fact your role is statutory and you write a report at the end means people take you more seriously though.”

Advocacy checklist

* Clarify commissioners’ arrangements jointly across health and social care settings.
* Identify a lead commissioner for the Imca service.
* Develop underlying principles for Imca commissioning, such as accountability, independence, empowerment, evidence-based approaches, shared learning, quality and effectiveness.
* Be clear about the differences between Imca services and other forms of independent advocacy.
* Develop a local strategy for commissioning Imca services.
* The Imca strategy plans should be developed in close partnership with health, social care and housing agencies to ensure that individuals who receive Imca support also have access to a wide range of services to provide comprehensive packages of care.

Extracted from Turning Point’s Guidance for Commissioners on the Independent Mental Capacity Advocate Service.

Further information
Imca

This article appeared in the 29 March issue under the headline “Following the Imca trail”

This weeks other feature articles:
Keith Brown reveals how Learn to Care’s study undermines Skills for Care’s claim on training funding

Daisy Bogg on how social care can avoid being marginalised in multidisciplinary teams

Change agents: councils’ critical friends