Thursday, 5 December 2013

Quality Performance Mark Update

In the last few months I’ve been asked by a number of people what is happening with the Quality Performance Mark. The future of the QPM has been up in the air for a while but now appears to be settled.

NDTI have taken on the QPM and are going to be going through a review process in the next few months. I understand that this means it will not open for submissions or renewals until April next year.

I’m proud of the role I played in developing QPM. Good luck to NDTI in their work of defining, assessing and celebrating protect high quality independent advocacy; protecting empowering services that make sure people’s rights are a reality. Something as important as advocacy has to be done well.

If you have any enquiries about the QPM they should be sent to

Friday, 25 October 2013

Whitewash and Wonderland

Anyone who has been following @sarasiobahn’s remarkable blog My Daft Life will know about the death of her 18 year old son whilst he was in an NHS care facility. In Sara's blogs, her son (referred to as Laughing Boy, LB or The Dude) comes across as a remarkable person. This young man had epilpesy, and he died whilst having a bath in an assessment and treatment unit. It is appalling that she is having to face the aftermath of this loss. It is obscene that the investigation into his death has become a battle.

She is now having to navigate her way through an internal investigation into the death of her son, and the nature of that investigation is becoming a little strange. It’s a worrying example of the lack of transparency of the NHS when dealing with failings. All those words about involving families, learning from events, transparency and openness that have appeared in so many reports recently seem stretched to breaking point here.

One aspect of that bizarre process is the trust's odd use of the word advocate. I know a bit about advocacy - I've spent the last 10 years developing standards and quality systems in advocacy. I'm interested in the relationship between formal and natural advocates. I think both are vital. Until processes and services are designed to suit people rather than systems people will need advocates of one kind or another.

Sara was told that she could have an advocate at stages of the investigation. This could be seen as a way of bringing some transparency to the process. By “advocate” they meant a friend or family member. No problem there; friends and family members often play a natural advocacy role. It’s not the same as an independent advocacy role (the thing that I know most about) because family and friends automatically have a level of conflict of interests, they have another role in that person’s life. As I said, not a problem when that is the person that someone wants to be involved. It’s an odd use of the term advocate, but it does have an echo in a piece of research on the value of advocacy and supporters in child protection proceedings.

The trust could have suggested that she could have an independent advocate; someone who would have no other role in Sara’s life, who would look out for and avoid conflicts of interests. That’s something that would be a legal right if this were a complaint process rather than an investigation. But that’s not what happened. As it turned out Sara asked a friend who also happened to be an independent advocate to be involved.

Then something odd happened. The trust said this person couldn’t be the advocate because they had a conflict of interests; she occasionally volunteers for a charity whose Chair used to work for the trust’s predecessor. I find it hard to see that as a realistic conflict of interests. And let’s remember, the trust had specifically not tried to find an advocate without a conflict of interests.
How big is the possibility of conflict of interests? Well, if the “advocate” worked for the trust it would be a BIG conflict. Used to work for the trust? Some conflict. Worked for a former worker of the trust – potential conflict. Volunteered for an organisation, being supported by someone who reported to someone who had retired from the predecessor of the trust? The phrase vanishingly small comes to mind.

I make it four degrees of separation. There's a theory that you'll be able to connect to anyone in the world in six. Given that, it would be hard to find anyone in a local area that can’t be connected to someone else through in four links.

Then the trust appear to have made an even stranger decision. They said that Sara had now forsaken her right to choose an advocate and that one would be appointed for her. And that this “advocate” would not be able to tell Sara about what was happening in the investigation.

So that’s someone that wasn’t asked for and who will keep information confidential from the person they’re meant to be representing. That’s not independent advocacy. It’s not a natural advocate. It doesn’t conform to any of the principles or reasonable expectations of what any type of advocate might be. I don't see how it can realistically be described as any form of advocacy. In fact, the word advocacy can only be used if the trust are employing the Humpty Dumpty convention that “words mean whatever I say they mean”.

So there was no advocate. A measure that was meant to introduce some transparency into an internal investigation into the death of a young man had been warped into another aspect of the investigation from which LB’s parents are excluded. The window into the investigation was blocked up. The circumstances of the death of LB need to be thoroughly and transparently. But how can anyone have confidence in the process where transparency is whitewashed, where Humpty Dumpty investigates?

Pressure from Sara's team of supporters and social media has led the Trust to reconsider, and Sara's original advocate is now to be involved again. As she said on an update post,

"Thanks to Team LB for such an instant and remarkable response to her removal, and the power of social media for such dedicated and collective support. And good on the Trust for listening and responding."
I'm really glad that this has changed, but this should never have been necessary. There should never have been a need to struggle and battle for support. It wouldn't have been needed if the trust had remembered that the focus here must be on Sara, her family and The Dude. Here's hoping the change on advocacy reflects a wider change.

Thursday, 19 September 2013

Comparative law - that's the way it is

Comparative law

Anyone remember the riots?
You know, the disturbances over a couple of nights in a few cities. A few hundred people were involved and the media was all over it. Come on, you must remember it. All night courts and massively harsh punishments delivered to make people clear that “this will not be tolerated”. Nick a bag of rice? That’ll be two years in jail. Remember it now?


Anyone remember the Mental Health Act? You know, that piece of legislation that was meant to protect rights of people in  psychiatric hospitals; a reaction against the barbarous excesses of the old asylums. The one that was amended in 2007 to ensure that people had support in understanding and making use of their rights. Oh you must remember it, the CQC report on it every year. They always say how people aren’t being given what is theirs by right. They talk about unlawful detention, of using the threat of being sectioned to keep people on the ward. They’ve reported year on year that the law is being broken in thousands of cases. God, the judges mustn’t be able to catch a break, eh? All night sittings for a few hundred offences, imagine what the work load is for dealing with these ongoing, systematic breaches of the law.
What’s that? No prosecutions? Not one? Well, surely it can’t be through lack of evidence, I mean there’s reams of the stuff in the CQC reports. And surely it can’t be through a lack of access to legal systems, I mean it’s the CQC. They must have a lawyer or two knocking around the place. Surely they’ve not been hamstrung by cuts to legal aid.

So what’s going on?

To the untrained eye it appears that depriving someone of their liberty and dignity are things best addressed by holding up a mirror and going tut. Depriving a supermarket chain of a bag of basmati will bring down the full force of the law. To my untrained eye this  is wrong.

It’s a comparative law system. Some laws are enforced, others are write only documents. What happens when a health service or one of its employees breaches the mental health act? What is the penalty when this is done again and again, year after year? Where is the motivation to change when your failings are reported on but nothing happens?

Laws or frameworks that are not enforced are mere fig leaves of protection; they tell us what should be and ignore what is happening. This has a corrosive effect on people’s understanding of the law and of their rights. As I remember the reason for punitive sentencing of rioters was that the rule of law would otherwise be undermined. The number of people who put up with injustices in the care system because “that’s just how it is” tells us that the rule of law has already been undermined here. Something needs to change.

Friday, 23 August 2013

The point of advocacy

Some people have asked me why I keep banging on about advocacy.

Well, imagine that you need support, or care, or housing or a GP.

Now imagine that you are routinely disbelieved or given poorer services.
That you don’t get access to a GP.
Or that your physical health problem are ignored or put down to your mental health .

Or imagine that you are in a care home where you are being abused by the staff.
Or that in your care home you feel like you have no say at all in what happens or what you do.

Imagine finding out that someone put a Do Not Resuscitate notice are put on your file.
That they did this without your knowledge because they believed your life had no quality or value.
That they didn't ask you because you are old, or have a learning disability, or have a diagnosis of depression.

Then imagine that there was a thing called advocacy that could help you be listened to.

Imagine the difference that it would make to have someone standing alongside you.
Someone whose presence actively demonstrates that they think that you matter.
Someone showing that you are not alone, that you are part of our wider society.
Someone who treats you with respect and who expects others to do the same.

Someone who helps you to be heard.
Someone who is there to make it harder for others to ignore your voice, you rights.
Someone who makes it harder to ignore you.

That's the point of advocacy. 
I think that's worth banging on about. It needs to be kept on the agenda.

Other people ask why anyone should care that Action for Advocacy has closed?

Well, put yourself back in that position.
If advocacy was available, you’d want to know about it. 
You'd want an advocate who could be there for you.
Someone who knew what they were doing.
Someone who could do these important things as well as possible.
Advocacy is too important to get wrong. 

Advocates need to be trained, accountable, clear about their role and supported to deliver this..
Advocacy organisations need to be robust, independent and able to challenge poor practices.
That's what a4a was trying to achieve. 
We got part of the way, but it can't be left there.
We need to talk about what happens next.

I need your help.
I want you to get involved, have your say & help decide what happens.
If you're interested email and I'll get in touch soon.

As ever, comments welcome.

Monday, 19 August 2013

Action for Advocacy - a kind of obituary

It is with some regret that I have seen the notice that Action for Advocacy has ceased trading.Although the organisation continues to exist for the present, I think it fair to assume that this marks the end of a4a as an active force.

In the past couple of months I have been asked about this many times by many people. In fact, I had expecting the future of a4a to be announced before I left the organisation in May. However, this didn't happen and I have not made any public comment until now. I was hoping to ensure that the future of the Quality Performance Mark was secured and, having  been informed that a new home will be found for the QPM, I want to flag up some of the organisation's work which I think deserves recognition.

Having started in 2001 under the name Advocacy Across London, a4a's work spanned 12 years that saw remarkable change in the independent advocacy sector. a4a started in a period when independent advocacy was only known about by a small group of people. The external perception of advocacy as that it couldn't make up its own mind about what it was. The idea that it would one day be a part of legislation was beyond fanciful. The idea that it would have an agreed quality framework, cited in commissioning guidance seemed implausible.

I joined in 2006 as the National Development Officer and held a number of roles since then. I'm proud to have worked with some remarkable people, to have been involved in an enterprise to try to make the vision of a strong and equal voice for all citizens a reality. I personally got to see the work of  a couple of hundred advocacy organisations and met countless advocates. Almost without exception, they were inspirational.

I believe a4a did some great work, and it did it with a pretty small team. I also know that a4a made mistakes, got things wrong and occasionally messed up on a grand scale (I'll put my hand up to a couple of those).  When it did that, it was usually because it was trying to do something good.

Now it's effectively gone.  I won't get into the why, how or who's fault stuff here, although I'd be lying if I said I don't blame myself to a certain extent. It was singularly unfortunate that I needed to take time off for health reasons at precisely the time a4a needed the most support.

Anyway, this is an obituary, not an autopsy. However,  I decided to take 5 minutes to jot down some of the things that a4a did in its time; just to take stock. Here's what I came up with...

  • The Advocacy Charter
  • The London Support Project
  • Developing A Code of Practice for Advocates 
  • Quality Standards for Advocacy Schemes
  • Founder member of Advocacy Consortium
  • Supporting the inclusion of advocacy included in the Mental Capacity Act
  • Promoting Independent Mental Health Advocacy in the  Mental Health Act
  • Human Rights Toolkit for Advocates
  • Promoting understanding of Non-Instructed Advocacy
  • Training over 5000 advocates
  • Developing and running the ILM accredited Managing for Excellence in Advocacy
  • Standards Support Project which supported hundreds of advocacy organisations raise quality
  • Developing the Quality Performance Mark
  • Member of the Care and Support Alliance
  • Representing independent advocacy in parliament
  • Advocates forums - both in person and online
  • IMHA support Project
  • IMCA support project
  • Free online map of advocacy services
  • Lost in Translation - developing a framework for recording soft outcomes in advocacy
  • Supporting organisations to prepare for contracts and tendering
  • Challenging poor tender documents
  • Representing advocacy organisations to commissioners
  • Planet Advocacy Magazine 
  • Advocacy Commissioners' Support conference and emails
  • 3 National IMCA conferences
  • Working with Welsh Government to develop monitoring framework for IMHA in Wales.
  • Highlighting shortfalls in IMHA commissioning in national media
  • Giving evidence to Joint Scrutiny Committee on the Social Care Bill
  • Review of rollout of IMHA in the North East
  • Review of learning disabilities funding in Wales
  • Review of use of IMCA in Safeguarding
  • Influencing the guidance on IMHA in Mental Health Review tribunals
  • First official review of the advocacy workforce
  • Keeping the sector informed on policy consultations
  • Input into CQC Mental Health Review report
  • Safeguarding courses
  • Responding to countless (and seemingly increasingly quick) policy consultations
  • Role of advocacy in financial abuse situations
  • Signatory of the Winterbourne Concordat
  • Hundreds of In House training sessions
  • Joint work with British Institute of Human Rights, British Institute for Learning Disabilities, National Development Team for Mental Health, Mind, Equality and Human Rights Commission, Scottish Independent Advocacy Alliance, Inclusion North, Valuing People Support Team, Advocacy Wales, Mental Health Foundation......
...and I know I've missed lots of stuff out. Some would say that's pretty good for 12 years. I know I always felt we needed to do more.Maybe that was part of the problem.

To everyone who worked at a4a in its lifetime - thanks for putting in your time, effort, energy and skills. You gave much more than you might have needed, you were committed to helping us change things.. For all trustees, thanks for your part in the journey.

We all believed in working for a society where all citizens can be sure of a strong and equal voice. We didn't get there, but I do think we made some difference and much of those ripples that we caused will carry on.  To the  funders, especially The Baring Foundation, City Bridge Trust, Department of Health, Awards for All, and Department for Education, thanks for supporting the work. In fact, this being a personal blog, particular thanks to the Baring Foundation for believing in independence, believing in us and for sticking with us. They are, without doubt, the most positively engaged  funder I have ever worked with.

In the end, we knew that we were only a small part of a story. The real work must be done by organisations, advocates and ultimately by those who challenge the inequality and poor service delivery that they face on a daily basis. In my time at a4a it was a privilege to meet so many committed, skilled and stubborn people who were determined to make a difference. That was one of the things that kept me going, through seemingly endless journeys on public transport throughout England and Wales. It is some comfort to know that there is no shortage of people out there who are carrying on that fight, championing voice, choice, control and dignity for all.

So raise a glass - for good or ill, a4a is no more.


....I wonder if anyone will miss us

Wednesday, 24 July 2013

To The Barricades?

In the last few posts I've used information from a CQC publication to show a few, widely acknowledged problems with the mental health system in England. The first showed that over 12,000 people are being denied their legal rights. The second showed that poor commissioning has led to people being denied their rights, and gave some suggestions for changing this. The most recent post pointed to wider problems of illegal detention and treatment of people in psychiatric hospitals, of an attempt by some staff to outsource their legal responsibilities for providing people information.

This collection of statements should shock us. The fact that most people who have had dealings with the mental health system will not be shocked by them troubles me deeply.There seems to be a widespread resignation  that things are like that, that change is unlikely, that we should settle for small victories. I no longer want to settle.

I've had a lot of discussions with people as a result of those blogs. Most agree that the situations is appalling. However, when asked how things should be changed the answers dry up somewhat.

Take the example of underfunding of IMHA services. IMHA is accepted as having a key role in supporting people to have more control over their care in very distressing situations.  Yet despite proof that IMHA is generally underfunded, that this has been known since at least 2009, that people have a legal right of access to this service and that this is being denied to thousands, nothing happens. People point out that if we were to fund the IMHA service properly it would lead to reductions in funding for other kinds of advocacy, that maybe we shouldn't be rocking the boat. I don't believe we should be picking and choosing which legal rights we are willing to fight for.

Given the importance that CQC rightly places on people having a voice in their own care, and the fact that CQC reports have repeatedly observed a systematic breaching of people's rights to an IMHA, I might naively expect them to take some action. I have been told that the noting of these breaches leads to a pressure, a knowledge that services should improve their practice, the weight of expectations. Unfortunately, I still believe the title of this blog is relevant - that the distance from "should" to "is" is immense. If CQC does not have some means of implementing the service improvement aspect of its role, of compelling  change in a system which it has identified is malfunctioning, it creates a vacuum that leads either to anger or despair.

So what happens next? How are professionals, services and commissioners meant to be held to account? Unless there is some concerted action by CQC in this regard, it appears that the responsibility lies ultimately on people who are being mistreated and denied their rights. I have heard many people say that things won't change until someone takes a professional or authority to court . Not so much "to the barricades!" as "To the barristers!"

I feel that this is highly unfair. It should not be up to the people who use a hospital to make the system work. Nevertheless, as things currently stand we are placing responsibility for maintaining dignity and rights upon the very people who are having these things denied them.

Personally I do not want to see the money that is so badly needed to support good care being diverted into legal battles, costs and damages. I don't want people to have to fight for good care. I don't want to see hard worked doctors or nurses sued for treating someone without obtaining their consent as a result of inappropriate threats of detention. These do not seem like good uses of energy, but in the absence of other moves towards addressing the situation they seem increasingly likely.

Of course, one barrier to legal challenges being raised is that often people aren't aware of their rights or of their ways of accessing justice. That doesn't have to be the case. There are ways in which people could be supported to raise legal challenges more easily; ways that a link could be forged between individuals, service user groups and the legal profession.

I'm reminded of the yellow card scheme for reporting undocumented side effects of medication. Any time someone talked about a doctor disbelieving them when they described unwanted side effects of the medication they were taking, you could pull out a card on which to record this and send it to a central point for collation. The view of one person might be discounted. The accumulated experience of hundreds or thousands are harder to ignore.

Think of how many service user groups there are out there. Think how many advocacy providers. Think how many local services or support systems for people facing mental health issues. These are all points of potential access, information and support.  Imagine how easy it would be connect these experiences now in this age of social media. Imagine how many legal challenges could arise - my quick calculation in my first blog puts the potential number above ten thousand. That's starting to sound quite expensive to me.

So should we spend public money ensuring people have dignified, appropriate and legal treatment that supports people towards recovery or should spend it instead fighting legal battles to defend a system that isn't working properly? I believe that positive change is the better route but I'm willing explore alternatives.

I'm in the process of developing an organisation called True Voice. I'm going to use it for various things, one of which is to do some campaigning.  If you're interested in continuing this conversation, either comment below or email me 

Wednesday, 10 July 2013

Bang to Rights

There’s a recurring trope in police and procedural dramas. After the chase, the bending of the rules, the adrenalin charge and the (inevitably) emotional arrest, someone starts to intone, “You have the right to remain silent….”. It’s not only about a grounding in the real world. It’s a signifier. The crisis is over, normal service has been resumed, justice has retaken its natural guise. Even in these hyper-charged dramas, you’ve got to tell people their rights, right? Right.

Now, imagine that you’re in a psychiatric hospital. You’re scared, but you’re not a criminal. You’re ill or at least perceived as being ill. If you’ve been detained against your will you are now experiencing the effects of  the Mental Health Act (MHA) one of the most powerful pieces of legislation on the statute books – and you’re on the wrong end of it. Unless you’re somehow working in the mental health area you probably won’t know what the powers mean. But now that the drama’s over you’ll be told your rights, right? Well, sometimes.

Giving people information about their rights is one of the obligations of those using the Mental Health Act. For that reason, it’s one of the areas examined in the CQC report, Monitoring The Mental Health Act. The data in the last report suggests that people are often not told their rights, showing that  10% of people appear not to have been given information about their rights under the Mental Health Act at the start of their detention. It stated that,

“MHA Commissioners reported a lack of evidence of staff discussions with patients about their rights on 458 visits overall. In some cases discussions had taken place but they were not recorded; in others patients were unaware of or unclear about their rights. In a number of cases the relevant forms (section 132) were missing or incomplete.”

Unsurprisingly, the area where the least information was given was on people’s right to access an Independent Mental Health Advocate (IMHA). One of the roles of the IMHA is to help people understand and realise their rights. There was no evidence of telling people of this right in 21% of records. There was often no effort to contact an IMHA service for the person if that person was unable to do so themselves. But I want to come back to rights in a wider sense, so I’m going to do something unusual. I’m not going to bang on about advocacy. I’m going to talk about outsourcing instead.

The hospital has the legal duty to tell people their rights. Usually this is delegated through ward staff, but the duty remains. That’s why I was alarmed to read the following section of the MHA report:

“The Code suggests that it will usually be appropriate for professionals working with the patient to provide the information about rights required by statute. In some instances, CQC is concerned to see this role delegated to IMHAs. Although IMHAs also have a statutory role to give patients information about their legal status, their rights and how to exercise them, this duty is described in the Code of Practice as an “additional safeguard”. It does not relieve nursing staff or other professionals who work under the direction of the hospital management of their duties under section 132.”
Well, quite.

Mental health staff can not outsource the provision of information about their own curtailment of people’s rights. That would be an abrogation of responsibility. It could be seen as part of a package where involvement, treating people with respect and dignity, supporting people to make their voice heard and ensuring person centred care is somehow seen as someone else’s job. Obviously this would never happen, it’s just hyperbole. Probably some glitch in the system led to a belief that discussing rights was the IMHA’s job, right? Erm,…

I’d be more inclined to believe that were it not for a long standing problem in mental health, one which prompts me to remind you what a psychiatric ward is. It’s part of a hospital – you know, the kind of place you go to for care and treatment. The combination of media portrayals of mental illness and the weight of the MHA can sometimes obscure this fact, but it’s important. So, not everyone on a psychiatric ward is detained under section. That means they can leave any time they want, right? Well, yes, but, only in theory.

In reality many people who are voluntary patients hit a barrier when they try to leave. They’re told that they will be sectioned if they go out of the door. So, you’re free to leave unless you try to. This piece of logic is so deliberately perverse it deserves the name Catch 23. And it is not legal. Yet anyone who has worked in mental health knows that this happens with depressing regularity. The powers which are regularly used by staff on psychiatric wards, to detain and to treat without consent, do not inherently arise out of a professional status. Nor is the loss of rights an inherent consequence of mental health problems. Both come from the MHA, a piece of legislation of that is meant to protect the rights of people. Using the Mental HEalth Act as a threat suggests a system too used to the concept of coercion, of enforced compliance. A system that has forgotten where its powers end.

The Mental Health Act Code of Practice could not state the law more clearly.

“4.12 The threat of detention must not be used to induce a patient to consent to admission to hospital or to treatment (and is likely to invalidate any apparent consent).”
I agree with the twitter commentator Ermintrude (Registered Social Worker, ex-AMHP and ex-Best Interests Assessor) this piece of information should be on an poster in every mental health ward in the country.

Because the thing about rights, the important thing, is that you can’t use them if you don’t know you’ve got them. And if your only means of finding out about your rights is through the very people most likely to infringe them, I’m not convinced that will work. It would be like asking someone to open a box with the crowbar contained inside it. Or like delegating the provision of information to an IMHA service you’ve not told the person about. Frankly, it would be madness.

So back to illegally coerced treatment.  How many care professionals have forgotten the meaning of informed consent, and the legal liabilities that attach to treating people without this consent? What legal options would you take if someone gave you powerful medication that can have serious side effects without your consent? I doubt I’d want to put it down to experience or accept it as the natural way that a system works. Yet every person who has been subject to the coercive threat of detention has experienced just that thing. It’s a wrong that is well known, and it needs to change.

I believe that it is vital that people know what their own rights are in care and treatment so that they can make use of them; so they can hold remind care professionals of their duties and protect their own rights.

So this is where I ask for your help. What are the common wrongs that you know about? What information should everyone have available? Either leave a comment below or email and I’ll see what I can put together.

Next time, a question of accountability.

Tuesday, 2 July 2013

A legal wrong

In my last post I showed that at least 12,000 people are being denied there legal right to access independent mental health advocacy. The CQC report  -Monitoring the Mental Health Act also states that 1 in 8 people who contact the IMHA service don't get to see an advocate. Given that IMHAs have a duty to respond to referrals, yet the report says that 1 in 8 people who request an IMHA do not get to see one. How can that happen? Are advocacy services wilfully ignoring their legal duties?

My experience suggests not. It has been known since 2009 that advocacy services have been  underfunded in regards to IMHA provision. This was recognised in the CQC report for 2010/11. Since then, despite increasing use of compulsory powers of the Mental Health Act, the funding of IMHA seems to have (at best) stayed constant. If demand increases and supply stays constant a shortfall is inevitable. There is  a problem with commissioning.

If the role of advocacy is to be developed in any way as a result of the abuse at Winterborne View, it would be in ensuring regular access to in-patient settings that do not depend on a referral. However, the CQC report shows that  roughly one quarter of settings have  no regular access to IMHA. That means the lessons of Winterborne are a long way from being acted upon.

A regular IMHA presence within in-patient settings is necessary if people's rights are going to be real rather than theoretical. This regular presence reduces the ability for staff to block access to advocacy services, allows advocates to see the regular ward environment and gives advocates the ability to perform a minor, proactive safeguarding role; spotting and challenging poor practice affecting people they are not directly advocating for. These actions would not be sufficient to guarantee the safety of patients and residents in care settings, but that responsibility lies ultimately with care staff. Advocacy's small role here is to act as a warning, a reporting mechanism, a means of identifying problems before they become disasters.

However, many advocacy services do not even have the resources to respond to the specifically requested need they face, never mind providing more proactive services to reach those who might not be able to ask for advocacy themself. As a result many people who are eligible for an IMHA never find out about it, and many who ask for support do not receive it. Some IMHA services even find themselves having to make tough prioritisation decisions about referrals that they receive; referrals to which they have a legal duty to respond. Sometimes, by the time they can respond to someone, that person is no longer there. This is no small thing. It is the denial of a legal right, and it has major consequences at a personal, financial and legal level.

At a personal level, I suggest that being deprived of support you were promised at a time of extreme distress is far from ideal. It adds to distress and suggests that you are not a high priority; your rights are secondary. From a financial perspective, plans that people actively collaborate in are more likely to be effective and create long term well being. That's a lot cheaper than poor planning and multiple re-admissions. Oh, and the person themself will have a better experience and be more likely to be treated with respect. Thirdly, legal duties are meant to be enacted. They are made to be real and tangible, they are not meant to be put into statute for political expediency or as some kind of window dressing. Local authority commissioners now have the responsibility to for facilitating this.

So what about the commissioners? Now that responsibility for commissioning IMHA has moved over to local authorities are we likely to see the legal obligation to resource advocacy provision better met? The CQC report seems to project a positive picture. It cites the important report The Right To Be Heard by Karen Newbigging and colleagues at the University of Central Lancashire. This called (amongst other things) for IMHA to become an opt out rather than an opt in service. The CQC report states,

"Commissioning of IMHA services moves to local authorities in April 2013, although responsibility for promoting access will remain with providers. Local authorities will be taking on this commissioning role at a time of financial austerity, and CQC hopes that the recommendation of the research is heeded"
I find it surprising to see a regulatory body publicly deferring to hope over experience or expectation.

The need for some level of regular outreach presence does not seem to have been recognised sufficiently by commissioners, never mind presumed access. Advocacy services have reported funding levels that are reducing despite an increase in demand and eligible populations. Advocacy is simply not seen as a high enough priority and the right to advocacy is seen as fudgeable because those who lose out are unlikely to take the matter to law.

The commissioning of advocacy has been widely variable across local authority areas.Too often, contract size is determined before need is established. The person holding the advocacy commissioning portfolio seems to change with depressing regularity.

Does CQC's apparent reluctance to get involved in this aspect  this may be explained by the inherent difficulty of finding the person or persons responsible for commissioning advocacy. Without a direct line to influencing, might CQC find it difficult to exert influence in this regard?

It has been suggested by some that IMHA commissioning will only become a priority when a local authority is sued by someone who was denied access to a right set out in law. That seems to place the responsibility on precisely the wrong person. Who should challenge poor commissioning practice, an individual aiming to recover from a traumatic incident or a regulatory/monitoring body. CQC is aware of large scale, systematic failure to comply with legislation. It has publicly stated this in its two most recent reports on the Mental Health Act. Is there not some obligation to act on this? Surely  monitoring is not enough when improvement is so clearly needed.

So, not wanting to offer problems without some possible ways of addressing them, here are a few ideas that might help CQC to address this problem:

  1. Ensure that the line of CQC's enquiries about IMHA service commissioning goes via the Director of Adult Social Services. Local authorities can change their commissioning team as they see fit. The Director of Adult Social Services should know who is responsible for meeting this legal obligation.
  2. Ask to see how the funding allocation for IMHA has been related to the number of uses of compulsory powers of the MHA in that local authority. If the LA can't produce evidence of this it suggests that commissioning has not been taken seriously.
  3. Make the commissioning of advocacy, and particularly statutory advocacy, a core standard against which local authorities are judged in CQC inspections. CQC's framework already states that increasing and supporting service user voice and facilitating greater involvement in care planning are fundamental aspects of good care. IMHA is a particularly neatly defined method by which this can be measured. If the LA is not meeting its requirements where there is a legal obligation to do so, is it really likely to do so where it is merely good practice?
Until the commissioning of advocacy is better scrutinised and related to actual need, the legal right to advocacy will continue to go wrong.

Next time; why are mental health professionals not telling people their rights, some posters that should be put up in all psychiatric settings and a particularly worrying trend in outsourcing.

Wednesday, 26 June 2013

12,000 people - is that much of a problem?

This is the first in a series linked posts about thousands of people being denied their rights to an Independent Mental Health Advocate (IMHA). This isn’t merely some technicality in the implementation of a health system. 

Ask yourself this question, if you were detained against your will, or treated without your consent, would you want to know what was going on? As you try to find out why you're there - scared and confused, would you want to know what your rights were? Would you want to have someone there that to make sure you were treated with respect; that you were listened to? That is what an IMHA is there for. That's what thousands of people are being denied.

The lack of access to IMHA is a matter of systemic and ongoing breaches of mental health law relating to Independent Mental Health Advocacy.  Upcoming posts will address how the problem could be resolved and some wider underlying issues. This post looks at how big the problem is and why it matters.

Around this time last year I wrote a piece for the Guardian Social Care Network about thousands of people being deniedtheir rights. People subject to compulsory powers of the Mental Health Act, whether in hospital or on a community treatment order, have a right to an independent mental health advocate (IMHA) to help them know their rights and to ensure they have a voice in decisions about their care and treatment.  The Care Quality Commission’s report on the MentalHealth Act (2010/11)   showed that for many people this was not the case.

In January this year, the CQC released their report on theMental Health Act 2011/12. I was hoping to see some changes as a result of the previous report, and indeed there were some. For example, the report showed that people were more likely to be informed of their legal right to see an IMHA.  There was also a rise in the number of wards on which an available IMHA service was found and the attendance of an IMHA when one was requested.

Mental Health Act Report Area
Is there evidence of an IMHA service?
Do patients have regular access to an IMHA?
Does the IMHA come when requested?
(Taken from figure 11 of CQC report)

However, as these areas are meant to be guaranteed by the Mental Health Act, these figures should be close to 100% . The CQC report shows that their reality is still far from guaranteed. That means that the table could be presented like this:

No evidence of an IMHA service
No regular access to an IMHA
People who requested an IMHA who didn’t get one

Percentages can be a bit dry, so let’s put some real numbers to that. The CQC report states that there are approximately 61,000 people detained in a hospital setting at any one time. This means that last year 6,710 people were detained somewhere that there was no evidence of a safeguard to which they are legally entitled. Last year 15,860 people were detained but had no regular access to someone who could help them know their rights and speak up alongside them. And even where people requested an IMHA, 7, 320 didn’t get to see someone. One in eight people that had requested access to a service to which they are legally entitled never received it. One in eight.

Whatever way you slice it, somewhere between 7,000 and 15,000 people in hospital last year were denied something promised to them in law. Given that the report also showed minimal awareness of IMHA amongst the 5,000 people Community Treatment Orders, the figure would rise above 12,000.

12,000 people can be a bit hard to visualise, so here’s some ways to think about it.

  • It’s more than the entire English based staff of the Care Quality Commission, Department of Health, Department of Communities and Local Government, Crown Prosecution Service and the UK Space Agency (although, to be honest, there are only 40 of the latter.)
Prefer a sporting example?

  • When Andy Murray walks onto Number One Court at Wimbledon today he will be playing in front of a capacity crowd of 11,430. Or put another way, it’s more than the entire crowd that watched Burnely vs Crystal Palace in January 2013 (11,564).
If you prefer culture to sport...

  • Get the massed audiences of packed houses at Royal Albert Hall, Hammersmith Apollo and Royal Opera House combined – that’s about it.
Now imagine the news report that says that an entire football stadium is denied its rights, that all those at Number One court today will be failed by a system, that the staff of those government departments will be failed by service commissioning, delivery and regulation. That this state of affairs will be known but not acted on. That this will go on for years.

I dare you to walk onto the pitch at Turf Moor and tell the crowd that you're going to do that to them. I wonder if the staff of those government departments and agencies would feel it a mere problem of implementation if it were happening to them. Well, it is happening right now to people who have been diagnosed with mental health problems. It's been set out in black and white in numerous reports, yet it doesn't seem to create much alarm. Is it the stigma of mental health that prevents us from being up in arms about it?  I don't know, but it needs to change.

Next time, I'll give some practical examples of what I think what needs to change and how we can make them  happen. For now I ask that you accept that this is a major problem.

Wednesday, 20 March 2013

Getting From A to B

The Distance From Should To is…. It’s an idea that fascinated me for a long time. Usually it's a way of comparing policy, theory and announcements to reality. This time it’s about me.

It’s been a while since my last post, and some might think that this gap is a little curious given the recent select committee report on the Draft Social Care Bill. I’ll write about the draft bill shortly but first I’ll talk about the gap.

I’ve just returned  to work following sick leave. Late last year I reluctantly accepted that:

a)   I was suffering from depression
b)   It was stopping me working properly

It took me a long time to get from a to b.

I don’t intend to speculate on the reasons for depression or to spell out the effects. There are other bloggers out there that can do that far better than I. But other people’s openness about their own mental health issues is something I’ve always admired. It was really useful to me when I was finding my own way through. It seems only fair to add my own small contribution.

I also want to publicly acknowledge that there was a problem, particularly for anyone who may have been wondering why I’ve been so bad at communicating with them recently. It wasn’t you, it was me…., back to me.

I should have taken time off earlier. One of the things that stopped me was the belief that I would be able to turn things round. Even when I accepted that I had depression I didn’t accept that it meant that I would be affected by it. Other people? Yes. Me? No.  

I should have been able to sort things out. I was able to seem ok to most people, surely that meant I was almost ok. I was convinced of this, so I piled more and more pressure on myself.

I always felt that I just needed to sort out one more thing. I’d take some time off in a bit, but not just now. The problem was that I was dealing with what should be, not with what was really happening. As a result I worked longer hours, achieved less, and got worse.

If I had broken my leg I wouldn’t have expected myself to keep running. However, despite a lifetime working in and around mental health, I couldn’t accept that depression would reduce my ability to get things done, so I kept going. In retrospect, this was a special kind of idiocy.  It was harder to sort things out, many things didn’t get sorted. I got worse.

Recently I’ve been asking myself why I was so reluctant to accept the impact of my depression. I've came to the uncomfortable realisation that despite many years trying to reduce the stigma and prejudice that people with mental health problems face, despite being a fan of the Time To Change campaign and the Black Dog Tribe, when it came to me I was somehow ashamed. Other people would be affected by mental health problems. Somehow I thought that shouldn’t apply to me.

Well, it did apply to me.

Taking time off was one of the scariest things I’ve ever done. It was probably one of the best things I’ve ever done. As the eagle eyed amongst you may have noticed from my profile, although I’ve returned to Action for Advocacy, I’m not coming back as Chief Executive. I need to make sure I’m able to put some things into that wonderful pile marked “someone else’s problem”, but believe me, I have enough to get my teeth into.  So let me finish by saying a few things both you and I should already know.

Depression is as real as physical illnesses. It has as great an impact as physical illnesses or injuries. I expect that our society should treat mental and physical health problems with a parity of respect and understanding. Mental health problems no more define a person than does a fractured rib. I have spent years of my life challenging fears, assumptions and prejudice about mental health. It’s strange to realise that one of the most ingrained problems was sitting in my own head.