Effective commissioning of advocacy under the Care Act based on emerging good practice

This section outlines six key steps to strengthen the commissioning of advocacy under the Care Act and illustrates some of them with practice examples.  

Understanding what advocacy is and the need for independence

Everyone involved in social care locally needs to develop a clear understanding of advocacy, why it needs to be independent, its various forms, the legal context, its role in implementing the Care Act wellbeing principle and duties in relation to prevention as well as supporting  peoples’ involvement in their care. This includes capacity building and support for commissioners and frontline staff, including co-produced training, to develop an understanding of advocacy and their roles in promoting and supporting access and uptake.

Frontline staff not understanding advocacy was identified as a major barrier to access and uptake of advocacy under the Care Act and this may skew the assessment of need and demand.
Commissioners not understanding advocacy can result in commissioning advocacy services that are ill-equipped to provide meaningful advocacy. Relying solely on spot purchasing is an example of commissioning practice that is instrumental. It does not locate advocacy within a framework of promoting greater choice, control and ultimately wellbeing.

Similar to independent mental capacity advocates (IMCAs) and independent mental health advocates (IMHAs), independent advocates under the Care Act are expected to be appropriately trained, and hold the National Qualification in Independent Advocacy (level 3).

However, other advocates, for instance generic advocates or citizen advocates, who do not hold this qualification can support involvement in decision-making under the Care Act. Such advocates could be appointed as independent advocates under the Care Act and be working towards the qualification within their first year in the role. Some local authorities clearly understood this and were viewing Care Act advocacy within a broader understanding of advocacy. 

We define everything as Care Act advocacy if they meet the threshold and it’s about their life, they get an advocate... I think there is a mix-up about advocacy – it’s not just about the law. We call it social care and community advocacy. It is difficult to define but if someone needs an advocate, they get it.

(Commissioner, interview)

Commissioners need to be knowledgeable about advocacy and the role it plays in both protecting individual rights and promoting wellbeing. They should understand:

  • the different forms of advocacy including generic and citizen advocacy
  • there can be an overlap between IMCA and advocacy required under the Care Act. This is a complex area but people who struggle with decision-making do not necessarily lack the capacity to make a decision regarding their care and support
  • the importance of independence from service provision. This is critical as conflicts of interest can arise if the service providing advocacy also has a role in providing care and support to individuals. This does not mean that social workers, care managers or care providers cannot promote an individual’s views but it does mean they cannot act as independent advocates  
  • advocacy under the Care Act services work well when there is an information and advice service in place to deal with a broad range of queries regarding social care, and means that the advocacy service is more likely to receive appropriate referrals.

Embedding co-production in commissioning

Advocacy under the Care Act should be commissioned in meaningful partnership with people who use services and carers. Co-production is not easy and there are fundamental differences that have to be negotiated, including roles, responsibility and accountability. For co-production to flourish, both within advocacy providers and in local authority commissioning, organisational structures and culture, staff values and attitudes may need to change and develop.

Co-production in commissioning is a leap up from consultation, involvement and engagement. It adheres to underpinning values and principles driven by the user movement.  These values also form the bedrock of advocacy provision and so easily lend themselves to commissioning advocacy under the Care Act.

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Responding to local needs and diversity 

Commissioners need to provide advocacy services that reflect and meet the diversity of the needs of local people. Commissioners should conduct needs assessments, using a range of methods, to embed equality and diversity into the scoping, design, provision and monitoring of advocacy services.

Limited needs assessment and lack of consideration of diversity risks a single provider being commissioned that is able to meet the needs of the majority, but does not provide equal access to advocacy for all local people and further disadvantages minority groups.

Co-production with users, carers and the wider community, a population needs assessment and an equality impact assessment for advocacy will all support commissioning that responds appropriately to local need. This should include an analysis of demographic data, referral for assessment and support to the local authority, as well as events (open space events, focus groups, surveys) to identify the range of views and preferences for providing advocacy. Particular attention should be paid to:

  • older people
  • people from black, Asian and minority ethnic (BAME) communities
  • people with learning difficulties, physical disabilities and/or sensory impairments.
  • lesbian, gay, bisexual and transgender people
  • asylum seekers
  • carers.

The views of people from these groups may be overlooked and proactive measures need to be adopted to ensure they are included because they may have specific preferences for advocacy provision or face particular barriers in accessing advocacy. Partnership working between different advocacy providers can increase access to advocacy for marginalised groups and promote learning across the sector.

Supporting access to advocacy

Advocacy is a complex field and can sometimes be confusing for people who use services and professionals. Finding the right type of advocate and working out eligibility for statutory advocacy can be bewildering. Introducing a single point of access for all advocacy is one way that some local authorities have looked to ensure that people can access advocacy appropriate to their needs.

People should be able to access different types of advocacy according to what they need. There are overlaps between different forms of statutory advocacy and also informal advocacy (e.g. peer advocacy, generic advocacy, citizen advocacy and self-advocacy). All of these have a critical role to play in enabling people who use social care to have a greater voice and more control over their lives. Some areas favour the hub model, which provides a single gateway to a range of advocacy provision. They report that one critical advantage of this model is that it can be easier to respond to people’s individual needs providing access to different types of advocacy through a range of specialist providers. It can also facilitate long-term relationships whereby a single advocate may adopt several advocacy roles (e.g. IMHA, IMCA, generic advocate) with an individual service user as their needs and eligibility for advocacy changes. 

Local authority respondents and providers identified a lack of clarity about people who are placed out of their ordinary area of residence as problematic. It can result in a person not accessing an advocacy service, which in the context of high-profile failures in the quality of care, jeopardises wellbeing and safety.

Practice example: The Manchester Advocacy Hub

Whilst a hub model might work well in some areas, and particularly in an urban context, this may not be the most appropriate practice in all areas; for example, some rural areas  that have a limited number of providers, and where understanding the nature of the dispersed population and geography is vital. Key to effective commissioning is recognising that ‘one size does not fit all’ and the local context (population, geography, local views and provider capacity) play a role in determining the appropriate model.

Strategic and quality approach to commissioning

Commissioners should apply a good practice approach to the commissioning of advocacy under the Care Act, drawing on existing SCIE guidance and Commissioning for Better Outcomes: A route map. This includes:

  • working with advocacy providers to develop solutions and overcome barriers
  • incentivising providers to work together and with local communities recognising that partnerships take time and investment
  • realising the potential of market shaping and its role in building the capacity of user-led and community organisations to deliver advocacy under the Care Act
  • sustaining provision by agreeing three-year contracts as a minimum and including flexibility to respond to changes in demand.

Providers valued having both a block contract to ensure stability, and flexibility in the contract to respond to changes in demand. For example, a block contract for the majority of hours or contacts and the remaining proportion either to be billed to the local authority on a spot-purchase basis or an allocation. This could be used flexibly across all types of advocacy to respond to fluctuations in demand.

Commissioners and providers emphasised the importance of positive working relationships between each other, which enabled a developmental approach to introducing advocacy. Eighty per cent of the providers who responded to the survey indicated they had been involved in the commissioning process. Some respondents felt that this built on an existing relationship which can be positive but care must be taken not to exclude smaller, less well-known providers, for example, community based-organisations representing minority groups. [1] Positive relationships were characterised by commissioners understanding advocacy well, committing to sustaining provision and being willing to seek shared solutions with the provider.

We started from a low position but the commissioners were very open, it was a two-way process with open dialogue. There is a good level of referrals and steady growth. When there are problems or barriers, the commissioners are receptive and not defensive.

(Advocacy provider interview)

Organisational ’churn’, often as a consequence of austerity measures, can lead to turnover in commissioners who have a good understanding of advocacy and may result in an approach driven by contracting rather than commissioning.

Tendering for advocacy potentially favours larger organisations that have greater experience and capacity, and can result in smaller organisations no longer being viable. Associated with this, concerns were raised by providers about the lack of transparency in decision-making regarding awarding tenders. A limited choice of provider(s) can mean that there are potentially issues with the quality of provision.

Meaningful and proportionate monitoring to measure outcomes

Building the evidence for impact with user and community-defined outcomes rather than outputs, is central to sustainability. This should be supported by a simple and agreed system for data collection.

Commissioners described requiring a range of data for monitoring contracts, usually on a quarterly basis and, in some instances, monthly. This included access rates for advocacy, demographic detail and bespoke outcome measures as well as descriptive accounts of observations on trends in use of advocacy services, partnership working, co-production and case studies. Providers emphasised the importance of meaningful and proportionate monitoring. The opportunity to engage in dialogue with commissioners varied. Where this was evident it was clear that commissioners and providers were working together on meaningful outcome measures and using the information to improve services.

We proactively provide feedback and are seen as a critical friend to the local authority. We send reports on issues arising that both impact on the provision of advocacy (e.g. referrals not being made) and issues arising from work with people. With the Head of Safeguarding/Quality we are currently developing a plan of how the local authority is to address the issues arising.

(Advocacy provider survey)

Providers and local authorities emphasise the importance of advocacy being person-centred and achieving the outcomes that they want.  There is a risk that Advocacy under the Care act could become overly focused on local authority processes of assessment, review and safeguarding rather than the person. Effective advocacy needs to be timely so that a person can access it when they need it and also needs to be focused on the person and the outcomes they want to achieve. A key outcome should be enabling the person to self-advocate through building skills, networks and capacity using advocacy as a key opportunity.

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