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 a4aqpm@ndti.org.uk

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 

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 ask@truevoicetrust.org and I’ll see what I can put together.



Next time, a question of accountability.

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	2010/11	2011/12
Is there evidence of an IMHA service?	85%	89%
Do patients have regular access to an IMHA?	65%	74%
Does the IMHA come when requested?	86%	88%

(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:

	2010/11	2011/12
No evidence of an IMHA service	15%	11%
No regular access to an IMHA	35%	26%
People who requested an IMHA who didn’t get one	14%	12%

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.

The Credibility Gap - A Pitfall in Social Care

Why do some people find it so hard to be heard, to get the services they want or to be respected to make their own choices? It’s a question I’ve been discussing a lot recently as the Care and Support Alliance  try to ensure that the social care bill will give sufficient support to people to have true control over how their social care needs are met. 

So what gets in the way of voice, choice and control? Too often the view is  that the cause lies in the person – in their disability or the barriers that they have communicating. If that were true, this view would make assessment of who is eligible for advocacy simple; you could measure against a checklist. But phrasing it overlooks three really important facts.

First, not every disabled person needs or wants an advocate. Not everybody with learning disabilities, not everyone with a mental health problem, not every person with autism, not everyone in any group. To suggest that they do is to massively undermine the ability of people to speak for themselves.

Second, it suggests that the problem lies in the person, not the system.  I know of many people who have used advocacy who in almost any other situation are remarkable communicators. However, when they are trying to deal with systems, and saying the wrong thing can have long term consequences, communication gets tougher. 

Professionals can be hard to contact, are sometimes pressed for time, refer to knowledge you don’t have, use their own language, control access to services and don't always respond well to criticism. It is unsurprising therefore that people are reluctant to speak up and find it hard to be heard. Information and advice might help reduce this problem for some, but for many that is not enough.

But it is often a third factor that forms the biggest barrier; when the preconceived ideas that people have about you stop you being heard or having control over your life and your choices. This is something which I call the credibility gap, and it is expressed in many ways.

The credibility gap is what makes it harder for people with mental health problems to get access to good general healthcare – too often symptoms of physical problems are ascribed to psychological factors. It’s one factor in the under-identification of depression in older people. It’s what makes people with learning disabilities have the validity of their requests and statements challenged, as if they couldn’t possibly understand what they’re saying. It’s the barrier to justice when people in residential report abuse by staff to the police – because we know all care staff are nice and people in care can’t be believed, yes? These perceptions have been shown to be false countless times, yet they persist and compromise the dignity and rights of too many people in our society.

Put simply, the credibility gap is what you experience when someone has made up their mind about you before you’ve even spoken. It’s an expression of all forms of prejudice that allows people in power to undermine or ignore those who need something from them. And the credibility gap is not solely related to disability or age, it’s something that carers experience too.

The dreadful experience of Mark Neary shows this all too clearly. A devoted father and carer to his adult son, Mark faced the prejudice of care staff who decided that his relationship with his son was a problem. Every action he then made, all communications he had with care staff were viewed through this distorted lens. For over a year, Mark’s son was kept in residential care rather than being at home with his father. For Mark, this credibility gap was an impassable chasm despite his energy, perseverance and his eminent ability to communicate well (read his blog – it’s great). One turning point came when an independent advocate was involved who managed to challenge staff perceptions. Eventually the case went to court. Mark won and his son returned home, but the cost to all involved was considerable. That is not how social care should be.

As it stands, the draft social care bill ignores the effect of the credibility gap. Information and advice do not close the credibility gap. Independent advocacy can. (You might want to click on that link and suggest that there should be a general duty to ensure there is information, advice and independent advocacy.)

Even outside the context of the bill, without facing this injustice which so many people face we won’t get the balance of advocacy provision right. But far worse than that, we will be supporting the idea that the problem in communication is a deficit of the individual. It’s not. Rather, it’s a challenge for individuals, professionals, services and the state to address together; communicating openly, fairly and without prejudice to ensure we all have choice, dignity and control in our own life. 

A few simple questions?

In the past few days I've been asked more questions about advocacy than you would believe. Actually, I've been asked only a few questions, but they've been asked lots and lots of times...

What is an advocate?

Do advocates have special legal privileges?

What is a mental health advocate?

What is an Independent Mental Health Advocate.

..and most of these easy enough to deal with  (see Action for Advocacy latest news for some answers).

But the problematic one is explaining that while, yes, there is a well understood role of a mental health advocate (supported by and accountable to an advocacy organisation), it's also possible to describe yourself as a mental health advocate if you are not operating in this way.

This poses a problem for the advocacy sector and places a responsibility on the health and social care sectors. For advocacy: is there a way for us to make it easier for others to know what role and status someone has? For care providers: what steps are you taking to ensure you are clear about advocacy; its role, its boundaries and people's right to access advocacy.

I've worked for almost a decade (the last 6 years with Action for Advocacy) to try to clarify some of these issues. We've created the Advocacy Charter, A Code of Practice for Advocates, high quality training, the Quality Performance Mark and lots of information to help address this issue. We may think people should know about advocacy.

There's a reason this blog is called the distance from should to is, and it looks like we've still got a long way to go when it comes to developing a general understanding of advocacy. But that work is essential if we're going to ensure those who are striving to be heard and to have control over their lives are going to gain access to safe, effective and high quality advocacy. And that's a journey worth making.

All Rock, No Blackpool?

I’ve been thinking a lot about the Care and Support bill and the fact that it defines advocacy as a social care service for which there may be a need. Identifying needs is important.

Many years ago I did some research about needs evaluation in care planning. It turned out that there was a big difference between what was written in care plans and what was understood and known by ward staff. In general, staff were aware of and acted on a range of information that was rich, complex and arose from an ongoing relationship with the people on the unit. The care plan on the other hand was a bare essentials plan of must do actions. It often missed out some of the most important facts about a person’s needs and abilities because it was assumed that “everyone knows that”. The problem was that when the use of agency staff increased, not everybody did know that.  Lesson; sometimes we assume and imply too much when we really need to spell it out.

On that note, a recent meeting relating to the draft social care bill and white paper is worth exploring. The Department of Health’s interim report on Winterbourne View explicitly stated that the care white paper would explore the role of information, advice and advocacy. In that regard (and many others) it was surprising to see that so little actually appeared in the white paper about advocacy. However, it appears from the meeting at DH  that advocacy is implied within the need for information and advice within the bill. We can argue that it needs to be further developed, that the advocacy “bit” needs to be clarified as somewhat different to the information and advice roles, but we were told that advocacy hadn’t been entirely forgotten. The lessons from Winterbourne are too important for that.

In fact, looking through the principles of the white paper and the aim of the bill, it is hard to imagine the step change in services being delivered without advocacy. You could say that advocacy runs through the white paper like the words in a stick of rock, but I’m concerned that it doesn’t stand out clearly enough. If you haven't been told it's there, if you aren't plugged into the need for advocacy, then you won't notice the word advocacy.

And that means that at the moment with have a stick of rock with no “Blackpool” in it. If the need for advocacy isn’t explicitly spelled out it may get missed when guidance goes from national to local level, something which would reduce the chance of ensuring dignity, choice and control for all. We need the writing to be clearer. If you think so too, please get involved in the consultation on the Care and Support Bill website   – or sign up to Action for Advocacy’s 100 Words on Advocacy.

Caring For Our Future by Forgetting Advocacy?

I’ve just taken a quick look at  “Caring for our future: reforming care and support” and it seems to signal an end to the phrase “information, advice and advocacy”. Information? Yes. Advice? Yes? Advocacy?.....

Well in terms of advocacy there seems to be some misunderstanding, some rewinding of the clock, a whole lot of forgetting and a potentially risky future. Here’s the sum total of the report’s mention of advocacy.

“Advocacy services have been in place for more than 30 years, often providing support for people who lack mental capacity and who have no-one to act on their behalf. These services will continue to play a vital role in supporting people and we need to understand better the benefits of these services and how cost-effective they can be. We will therefore work with partners to develop and disseminate best practice and potential new business models”

That's it. 

Well, most advocacy is for people who have capacity. Overwhelmingly so. It’s not the lack of capacity to make a specific decision that leads people to need advocacy. Rather it’s the experience of not being listened to, not being included in decision making, being discriminated against, being abused, being in receipt of poor or inappropriate services or not being able to access services (including basic health care) at all. Those are the main triggers.  To focus on a lack of capacity risks locating the fault with the individual, not the services. 

And advocacy is not just for people who have no-one to act on their behalf. Not even the IMCA role is limited to this. Many of  carers I spoke to at the social care lobby of parliament talked about wanting an advocate for the person they looked after. And while I’m firmly behind the idea of getting a better view on the impact and effectiveness of services, I'm concerned that this single statement ignores a wealth of evidence pointing to the impact and value of advocacy. 

If that’s the case, forget all of those mentions about the importance of advocacy as a safeguard against abuse and in safeguarding processes. Forget the CQC's thematic review on learning disability services, ignore SCIE guidance on safeguarding, forget the lessons from Winterbourne view, forget the Kerr-Haslam report, forget all the other reports that make the same point. 

Ignore Valuing People, forget about the Care Quality Commission’s excellence framework. Forget about the NHS Confederation’s report Delivering Dignity. Forget the value that the Mental Capacity Act  Code of Practice puts on advocacy as a means of enabling people to be more involved in decisions about their lives (and no, that’s not a reference to IMCA). Forget EHRC's report "From safetynet to springboard". Forget the Law Commission’s report on reforming social, they were obviously having an off day when they recommended realising the right to advocacy for all disabled people. And I can only conclude that the Joint Committee on Human Rights was similarly confused when they supported the call.  Forget them both, forget them all, but remember this.

Every single time someone approaches an advocacy service, it is an indication that they believe some decisions about their life are out of their control; that something about them is being decided without them, that they are at risk or their voice is not being heard. A request for advocacy is a request for autonomy and control. It’s often a sign that the care and support system isn’t working. And, with the exception of some statutory provision, it’s a statement of belief from individual people that advocacy creates real change for them.

So when we look for the effectiveness, cost effectiveness and value of advocacy, let’s make sure we don’t choose models that ignore those problems or are incapable of offering credible solutions. And when it comes to decisions that materially impact on the lives of people who demand advocacy services, let’s live up to the statement  that the health white paper borrowed from the advocacy movement - “Nothing about me without me”.

Right answer, wrong question?

I recently got a birthday card that said “The answer is football. The question is largely irrelevant”. Someone knows me very well. When people hear organisations talk about the need for more advocacy provision they may well suspect the same kind of failing. It doesn’t matter what the question is, we’ll tell you that the answer is advocacy.

So today I spent the day with the Care in Crisis lobby of parliament and taking part in the online #twobby. I met many inspirational people, heard challenging stories from people struggling to get the right social care, met and had a good discussion with my local MP and heard Paul Burstow talk about his plans for the Social Care White Paper.  And I tried not to talk about advocacy too much, because the questions weren’t always about advocacy; they were usually about dignity, fairness, funding, appropriate services, connection to communities.  Advocacy isn’t the answer to these questions, but it is a mechanism that informs those answers.

So when we hear that people need support to navigate the new care system, that people need support speaking up, that getting appropriate care is a constant battle, that people are afraid of complaining on behalf of relatives, that closed care systems breed abuse  – well, advocacy is part of the answer. (If you don't believe me you may want to look at my previous post A Gap in Dignity and Rights.)

Paul Burstow spoke of a future where local authorities should be held to account within national frameworks of expectations. He has previously spoken of the role that advocacy plays in demonstrating that local authorities are meeting their equalities duties. Including a requirement to record the advocacy needs of a community in the Joint Strategic Needs Assessment would help local communities hold LAs to account on this; it would let us see the distance between should and is.

Then local communities would be able to check that there is at least one mechanism in place to address the real question; have we done enough to make sure that everyone's care needs will be met in a personal, appropriate and dignified way?