The Care Quality Commission recently celebrated a rise in the level of access to Independent Mental Health Advocacy, a legal right for people subject to compulsory powers of the mental health act. However, these headlines belie a more troubling situation which should concern mental health professionals and commissioners alike. When looked at in context, there is no cause for celebration.
In a series of blog’s last year, Martin Coyle highlighted a number of problems relating to mental health law in England. Using data from the Care Quality Commission’s report “Monitoring the Mental Health Act 2011/12”, he identified that thousands of people were being denied their rights to mental health advocacy, that there was no meaningful access to advocacy for up to 26% of people detained under section, that poor understanding of advocacy was leaving hospitals open to legal liabilities and that under-commissioning of advocacy was leaving public authorities similarly open to challenge.
The Care Quality Commission report “Monitoring the Mental Health Act 2012/13” reports on very few of the statistics highlighted in the previous report, choosing instead to highlight only two figures relating to IMHA; the report of ward managers of whether they have access to IMHA and the percentage of people who were aware of their right to IMHA. It highlighted a rise in reported access to IMHA (up to 92%) as a positive improvement. The data and our knowledge make this an uncertain cause for celebration, and this will be illustrated in three ways; through methodology, internal inconsistency and financial pragmatism.
The reported rise in access to IMHA is actually quite small, going from 89% to 92%. I am unsure whether this would count as being a statistically significant difference, even if the methodology were sound. However, though the report talks of a rise in access to IMHA, it actually shows only a rise in reported access. In other words, it tells us about the answers of ward managers, not the experience of people who are legally entitled to the support of the IMHA service.
In effect, this figure relates to the percentage of ward managers that, when questioned by an inspector from a regulatory body, state that they are meeting their legal obligations. In that context, it’s actually quite surprising that 8% of respondents said no.
In contrast, the previous year’s report asked people on mental health wards whether there was regular access to an IMHA. Whereas 89% of ward managers had said there was access to IMHA in 2011/12, the report showed that only 74% of wards actually had access. For those wards where there was no regular access to IMHA, the CQC reported that people’s access to their legal rights was “largely theoretical”.
When a report cites a minor rise in a measure which it had previously referred to as “largely theoretical” as a cause for celebration, we might well have cause for concern.
As the 2011/12 report clearly showed, using a range of measures to investigate the reality of access to IMHA allows us to go beyond rhetoric and self report to a closer understanding of the realities of care. In the 2012/13 report there is far less detail about access to IMHA. However, one statistic that is included is the percentage of people who were told of their right to access an IMHA. You might assume that, given the reported 92% access to IMHA, the percentage of people told that they were entitled to access the service would be at least 92%. In fact it was 82%, and that figure relates to situations where there was any evidence of this information being given. It does not show that this info was given effectively or appropriately. It does not in any way show that accessto IMHA was facilitated. Even viewed generously, this leaves 10% of people who are able to access a service they have not been told about. This stretches the credibility of the 92% figure close to breaking point.
The 2011/12 report specifically mentions a lack of resources for IMHA services which in turn leads to insufficient access to IMHA. This commissioning shortfall has been public knowledge since 2009, and has been reported on by many organisations including Action for Advocacy, Mental Health Alliance and the Care Quality Commission. in a striking figure from the 2011/12 report, CQC noted that even when someone requests an IMHA, they do not get to see on in 1 of 8 cases. Again, this was seen to be caused by lack of resources to meet demand.
So, my question is this. Having started with insufficient resources to provide access to IMHA which led to an inability to respond to 12% of requests, and having had funding either frozen or cut, and thereafter having seen a 5% increase in the number of people eligible for the service, how can access to advocacy have increased?
Lessons for hospitals and commissioners
In reality, access to IMHA has not increased in the last year. The ability of ward staff to adequately, appropriately and effectively support people to understand their rights remains inconsistent. The ability for people to have routine access to IMHA, to not be subject to gatekeeping of services designed to protect their rights and dignity, is highly quetionable. Such gatekeeping was seen in Winterbourne View. The fact that it is still possible in much of the mental health system should be a cause of alarm and shame.
To change this, local authorities must ask themselves whether the funding of IMHA services is sufficient to meet their legal responsibilities. Not doing so lets down people who depend on support of IMHA, and leaves local authorities open to legal redress.
Similarly, hospitals which do not inform people of their rights, which gatekeep access to IMHA are not only breaching the law, they are actively putting people at risk. Meaningful, timely and effective access to IMHA is one way that hospitals can show that they are taking respect and dignity seriously.
Martin Coyle, Director of True Voice has supported care providers, advocacy providers and local authority commissioners to investigate, review and improve their ability to meet legal obligations relating to voice, choice and control. If you are interested in such support, find out more on the True Voice website.