3 Independent Mental Health Advocates |
38. The 2007 Act gave qualifying patients the
right to support and assistance from an independent advocate.
The Secretary of State has a duty to make reasonable arrangements
to ensure this is available for qualifying patients who include
those under detention or subject to a community treatment order.
Independent Mental Health Advocates (IMHA) were, until April 2013,
commissioned by Primary Care Trusts. From 1 April this year commissioning
became the responsibility of local authorities.
39. In oral evidence Alison Cobb described the
IMHA role as a key improvement to the legislation and described
the service as "a really valuable provision and safeguard
for people who are in a very powerless situation".
Dr Chalmers added that clinicians knew that the service could
40. The Committee agrees that
the 2007 Act has improved safeguards for patients by providing
a framework for improved patient advocacy.
Access to advocacy
41. Recognition of the success of IMHAs must
be accompanied by a number of qualifications. Our inquiry confirms
evidence from the CQC that variation in access to IMHAs is a chronic
problem within the system. In 2012 the CQC found that in 21% of
care plans there was no evidence that patients had been informed
of their legal right to an IMHA.
Naomi James told the Committee that a quarter of patients were
unable to access advocacy, adding that there was "little
equity of access and the style of provision is variable".
Dr Chalmers said that providing good quality advocacy for patients
with disabilities or communication problems was a challenge
and Naomi James said it represented a "broader systematic
problem in mental health"
whereby services did not recognise a patient's needs.
42. Naomi James argued that advocacy services
were under pressure because "as the rate of detention increases,
there are fewer people (IMHAs) to go round".
Bruce Calderwood argued that the problems related to access were
not linked to the rise in detentions.
He also argued that trends around access showed that "the
problems of lack of access are reducing over time".
43. Anne McDonald told us that research undertaken
by the University of Central Lancashire found that for patients
"the more you needed an advocate, the more difficult it was
to access them."
Naomi James reported that patients "are not accessing IMHAs
and "staff are often unaware of the legal duty on wards to
Both Naomi James and Bruce Calderwood highlighted the CQC's findings
which pointed to considerable variation in the service available.
44. The Department of Health has acknowledged
that some patients have struggled to access IMHAs.
Dr Griffiths told us that a proposal that patients should automatically
be referred to an IMHA was currently under consideration by the
Department of Health.
45. We recommend that the IMHA
service becomes an opt-out rather than an opt-in service. This
measure would help address the difficulties patients face in accessing
advocacy and eliminate some of the practical problems clinicians
face in making patients aware of their right to request an IMHA.
RESPONSIBILITIES OF CLINICIANS
46. The 2007 Act is explicit in its instruction
that patients must be informed of their right to advocacy as soon
as is practicable.
Anne McDonald told us that clinicians should not only explain
to patients the rights that they have but that they should also
"be facilitating people's access to advocates".
Naomi James said that in some cases staff made decisions about
whether advocacy was required on behalf of patients.
Bruce Calderwood said that clinicians:
should not be judging whether it is in someone's
best interests to have an advocate, but it is people's statutory
right to have an advocate and therefore they need to be able to
explain the statutory rights if the person does not understand.
If the person is in a state of confusion and anguish, which will
be quite common when people are first admitted, then they should
explain regularly, until the person does understand it. The code
of practice is very clear on that.
47. Importantly, the CQC emphasises the point
that whilst IMHAs have a statutory role to inform patients of
their legal status and rights, this does not diminish the responsibility
of nursing staff and doctors to communicate this information to
patients. The CQC has warned that the presence of IMHAs should
not allow hospital staff to abdicate responsibility for this aspect
of patient care and they stressed:
in practical terms, nursing staff have much greater
contact with detained patients than IMHAs and are best placed
to ensure that patients get the best opportunity to understand
and exercise their rights.
Naomi James identified a link between the existence
of advocacy services and a retreat by clinicians from their responsibilities
to inform patients of their rights.
Dr Chalmers agreed that this represented a question of good professional
practice, explaining that
It is usually the nursing staff's core job to present
the rights and to go back to patients. In the first few days of
admission, people may be very distressed and may not want to engage
in a discussion about rights, so that should be re-presented repeatedly.
That is a requirement. If it is not happening, that needs to be
picked up by the CQC and the trust board, and those responsible
need to feed it back.
48. Although IMHAs have an important supplementary
role to play as independent advocates for patients, the Committee
is in no doubt that the patient's primary advocates should be
their clinicians. We
recommend that the review by the professional regulators of advice
issued to clinicians, which we propose in Paragraph 33 of this
report, should put this obligation for the clinician to be the
advocate for the patient beyond doubt.
COMMISSIONING AND FUNDING
49. Local authorities have been allocated responsibility
for commissioning the IMHA service which predominantly supports
patients undergoing NHS commissioned treatment. Local authorities
already commission Independent Mental Capacity Advocates (IMCA)
and Bruce Calderwood explained that as local authorities already
commissioned an advocacy service this reform would build on "the
ability they already have".
Simon Lawton-Smith questioned whether local authorities would
have the knowledge and skills to commission services which meet
the needs of a range of patients.
50. The Committee accepts the
basic logic of combining commissioning for similar advocacy services
and believes that these added responsibilities represent an opportunity
for local authorities to broaden and deepen their skills in this
field. There is no regulator of independent mental health advocacy,
so commissioners play a vital role in ensuring that advocacy services
are of the necessary quality. We therefore urge local authorities
to work cooperatively to ensure that patients across the country
can access effective advocacy services.
51. The Department of Health told us that £9.2
million had been made available through the local government funding
formula to support the commissioning of independent advocacy.
This funding is not protected by ring-fencing and will not be
tracked to ensure that it is used for the intended purpose.
52. The Committee agrees that
local commissioners should manage their own priorities and budgets,
but draws their attention to their statutory duties in this respect.
It recommends that every Health and Wellbeing Board should seek
specific and quantified evidence from their local commissioners
to satisfy themselves that these statutory duties are being discharged.
The role and function of advocates
53. Simon Lawton-Smith outlined concerns that
the right to an IMHA did not extend to patients who voluntarily
admitted themselves to hospital. Dr Griffiths explained that at
the time of the 2007 Act IMHA services were not extended to voluntary
patients as "it was felt that extending the formal IMHA role
to all patients could destabilise some already existing good advocacy
Mr Calderwood and Mr Lawton-Smith acknowledged that policy in
Wales had been reformed to include voluntary patients within the
Welsh IMHA service.
54. Patients in hospital voluntarily
are often equally as unwell as those detained under section. Voluntary
patients enjoy few safeguards, and the Committee believes there
is a compelling case to extend advocacy provision to this group
of patients. Advocacy for patients with mental health problems
is now well established and protecting existing services is not
sufficient reason to exclude vulnerable people from a valuable
service. IMHAs offer crucial assistance to patients and the Committee
recommends that the 2007 Act should be amended to extend entitlement
to IMHA support to all patients undergoing treatment on psychiatric
wards or subject to CTOs.
55. There appears to be some uncertainty over
the scope of advice and guidance which IMHAs are able to offer
to the patients they help. Anne McDonald told the Committee that,
other than offering legal advice, IMHAs can provide formal advice
to patients regarding the steps they should take and how to make
best use of their rights.
This, however, is at odds with the Action for Advocacy code of
practice which states that the advocacy role should include "gathering
and presenting up-to-date and accurate information to help service
users make informed choices but NOT [their emphasis] giving advice.
Providers of IMHA services such as the charity SEAP say that advocates
cannot "offer advice, opinions or judgements about what is
best for you."
56. Alison Cobb told us that it would be "worthwhile"
to consider extending the scope of the role and Naomi James concurred
that advocates should be able to act as more formal advisers.
57. Part of the value of an
IMHA lies in their ability to provide patients with advice which
covers both mental health legislation and the health system. The
Committee recommends that the Department should issue new guidance
which clarifies both the scope and limitations of the advice and
support which IMHAs are able to provide. The Committee also recommends
that the Department should ensure that the training and accountability
systems for IMHAs are appropriate in the context of the role they
are expected to fulfil.
42 Q 12 Back
Q 17 Back
Care Quality Commission, January 2013, p 5 Back
Q 11 Back
Q 25 Back
Q 15 Back
Q 97 Back
Q 98 Back
Q 11 Back
Q 11, 95 Back
Department of Health, July 2012, p 11 Back
Q 97 Back
Mental Health Act 2007, section 130A Back
Q 102 Back
Q 11 Back
Q 103 Back
Care Quality Commission, January 2013, p 25 Back
Q 15 Back
Q 16 Back
IMCAs offer a similar service to IMHAs but support patients who
lack capacity rather than those suffering from severe mental illness.
These are typically patients in social care who have dementia
or severe learning difficulties. Back
Q 99 Back
Q 12 Back
Q 94 Back
Qq 100 -101 Back
Q 122 Back
Q 119 Back
Action for Advocacy, May 2006, A Code of Practice for Advocates,
p 8 Back
Q 12 Back