Commissioning and monitoring of Independent Mental Capacity Advocate (IMCA) services
Demand for the IMCA service
Local authorities are required to ensure that an IMCA service is available for those people who meet the criteria set down in the Mental Capacity Act (MCA) 2005 and the IMCA expansion of role regulations.
The initial estimates for the cost of the service by the DH made a number of assumptions for England including the following:
- There would be 10,000 IMCA instructions annually for accommodation decisions.
- There would be 6,000 IMCA instructions annually for serious medical treatment decisions.
- There would be 12,500 discretionary instructions for care reviews or safeguarding adults cases.
- IMCAs would spend an average of eight hours on most instructions. Additional time would be needed for more complex cases.
These assumptions give an average of about 55 IMCA instructions per year for an all age population of 100,000. For an adult (16+) population of 100,000 this would be 68. IMCA instructions.
There continues to be significant local variance regarding the level of instructions for the IMCA service which cannot all be attributed to differences in population profiles. For example, in some local authorities, eligible instructions in year three exceeded 40 per 100,000 population (all age) while in others it was below 5. Some IMCA providers report at times difficulties in meeting the demand for the IMCA service, however in other areas IMCA services are working under capacity.
Commissioners may want to calculate the rate of instructions for the size of their local population as part of the process of setting targets for the levels of activity for the IMCA service.
Use of discretionary powers
There is concern as to whether the discretionary powers to instruct an IMCA are being used effectively. Section 5.23 of the MCA Code of Practice says that all practical means should be used to enable and encourage the person to participate in best interests decisions. The instruction of an IMCA is a practical measure which should be considered in all cases where the discretionary power is available.
National data from the third year of the IMCA service shows that there were over six times as many accommodation instructions compared to those for care reviews. This raises two serious questions. The first is whether Section 7 guidance of undertaking a review within three months of a change in accommodation, and then at least annually, is being followed consistently for those people lacking capacity to make decisions about their accommodation who have no one appropriate to consult. The second is whether all possible support is being provided to people to participate when care reviews are arranged. For example, if an IMCA was instructed at a time when a person was moved to a new service, there would need to be clear justification as to why an IMCA was not instructed for all the subsequent care reviews.
The MCA Code of Practice (10.61) expects local authorities and National Health Service (NHS) bodies to establish a local policy for determining when an IMCA should be instructed for care reviews and safeguarding adults. Many local authorities have developed their guidance on IMCAs’ involvement in safeguarding adults based on the ADASS/SCIE guidance.
Few, if any, have established similar guidance for the involvement of IMCAs in care reviews. Template policies for health trusts and local authorities are now available in the newly published ADASS/SCIE Practice guidance on the IMCA role in accommodation decisions and care reviews(2010).
Commissioners should identify whether these policies are available locally and if so whether they need to be reviewed.