Findings from 2016 study

This study was conducted to identify good practice and summarise research findings from the Universities of Birmingham and Central Lancashire. It includes messages about effective commissioning and the early implementation of advocacy under the Care Act, as well as practice examples. It draws from surveys of local authorities and advocacy providers.

Key findings

  • There was evidence of promising practice in the commissioning of advocacy under the Care Act but several local authorities had initially adopted a cautious ‘wait and see’ approach. 
  • Some local authorities were still to specifically commission advocacy under the Care Act.
  • Under half of local authorities (47 per cent) reported involving people using or likely to use social care and family carers in the commissioning process.
  • There was wide variation in the methods local authorities used for estimating likely demand for advocacy.
  • The majority (60 per cent) initially commissioned a single advocacy provider, with 38 per cent commissioning a service ‘hub’ or partnership with a lead provider.
  • Less than 10 per cent of the local authority sample reported spot purchasing as the only method of commissioning advocacy under the Care Act.
  • More than half of providers considered arrangements for referral as not working well, often attributing this to frontline staff’s lack of understanding of their duty to refer.
  • In some areas, there had been fewer than 10 referrals since April 2015, and in others over 400. 
  • Local authorities reported prioritising statutory advocacy as a result of financial austerity: 22 per cent of commissioners reported either stopping commissioning or reducing access to non-statutory advocacy during 2015/16.

Effective commissioning

  • Understanding advocacy and the need for independence Open

    Everyone involved in social care locally needs to develop a clear understanding of advocacy, including:

    • why it needs to be independent
    • its various forms
    • the legal context
    • its role in implementing the Care Act wellbeing principle
    • its duties in relation to prevention as well as supporting  peoples’ involvement in their care

    To develop an understanding of advocacy and roles in promoting and supporting access and uptake, those involved should look at capacity building and support for commissioners and frontline staff, including co-produced training, to develop an understanding of advocacy.

    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.

    It is expected that now the Care Act has been in place since 2015, advocacy training should be embedded within current training for all staff, and refreshed as appropriate.

    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 Open

    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, processes 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.

    Find out more:

  • Responding to local needs and diversity Open

    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 Open

    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 Open

    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
    • working with people who use services, carers and the local community to understand what is important to them
    • 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.

    You may find the asset-based approaches information pages useful, as well as the reports and learning from the innovation network.

  • Meaningful and proportionate monitoring to measure outcomes Open

    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. Advocacy under the Care act should not have 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.

  • References Open

The implementation of advocacy under the Care Act

  • Statutory and non-statutory advocacy Open

    Some commissioners distinguished between statutory and non-statutory advocacy and as other studies have identified, are prioritising the funding of statutory advocacy including advocacy over community and other forms of advocacy. Twenty-two per cent of commissioners reported that they had either stopped commissioning or reduced access to non-statutory advocacy during 2015/16. Viewing all advocacy as covered by the Care Act was identified as one way of protecting wider forms of advocacy from budget restrictions. The majority (87 per cent) of local authorities in the study were commissioning advocacy for their area only, with the remainder commissioning jointly with neighbouring local authorities, and in a small number of instances, with the clinical commissioning group (CCG).

  • Watchful commissioning Open

    It was evident, that many had approached the introduction of the duty to provide advocacy under the Care Act cautiously; using the first year to better understand the need and demand, and to develop service specifications. Four out of five local authority respondents had developed a specification for advocacy. Not all, however, had as yet gone out to tender specifically for advocacy under the Care Act at the time of the survey (29 per cent extended an existing advocacy contract and 48 per cent had gone out to tender in 2015/16). The picture that emerged was one of a ‘work in progress’, perhaps unsurprising given the timing of this study:

    The contract is for another year, extension of an existing contract. We wanted to work with them (provider) in collaboration to understand impact of the cuts and how Care Act advocacy needs to develop. We’ll be going out to the market tendering for Care Act advocacy in four to five months’ time with an outcomes-based specification.

    Commissioner, interview

    It was evident from interviews with advocacy providers that some local authorities had not specifically commissioned advocacy under the Care Act and that the advocacy provider was being expected to provide increased advocacy services without additional resource:

    We have always been able to provide a quick response for advocacy but currently have 50 people on the waiting list. Our advocates currently have an average caseload of 30 people but they are very experienced. We have asked for additional hours to respond to the demand but have had no response from the local authority. We are now having to prioritise but some of our waiting list is due to spending time chasing social workers.

    Advocacy manager
  • Needs assessments Open

    Seventy-eight per cent of local authority respondents had undertaken a needs assessment to estimate likely local demand for advocacy as recommended by SCIE’s good practice guidance. This, however, varied from using quite crude measures to much more sophisticated evidencing of need. Likely need had variously been estimated with reference to local and national information and guidance, for example, the number of local community care assessments, past and current use of advocacy services, and the Department of Health’s 2014 Impact Assessment. [1]

  • Co-production Open

    Forty-seven per cent of local authorities stated they had involved adults with social care needs in the commissioning process for advocacy. Some who were in the process of developing their specification were involving users and carers as well as advocacy services in this, including a ‘series of co-production events from inception of delivery model to writing of the service specification’, in developing the new model, while others had engaged in consultation exercises and had relied on getting a steer from existing customer feedback mechanisms. Others indicated their intention to involve users and carers in the future:

    Although the answer to this question is ‘no’, we had involved service users in the original advocacy tender for IMCA/IMHA and general advocacy. It was this contract we extended to cover Care Act advocacy. We also ensured local service user groups were aware of their right to advocacy support under the Care Act.

    Commissioner, survey
  • Models of advocacy provision being commissioned Open

    The majority (60 per cent) described the model for the provision of advocacy under the Care Act as a single provider model, that is, one advocacy service had been commissioned to provide advocacy. Another 38 per cent referred to partnerships and consortiums of advocacy services which they referred to as ‘integrated advocacy service’, ‘partnership model’, ‘framework’ or an ‘advocacy hub model’ with a range of contractual arrangements often with a lead provider acting as the gateway to other providers offering different forms of advocacy to different user groups. Spot purchasing according to need was a less common practice amongst the survey respondents than reported in other studies. [2]. Since April 2015, 27 per cent of respondents had changed advocacy provider due to arrangements being interim, learning together with the advocacy providers what was needed, and social care commissioning processes evolving, for example, to become more outcomes-focused. [3]

  • Evidence of variation in spending on advocacy under the Care Act Open

    Commissioners and providers reported wide variation in the total spend on advocacy, ranging from contracts of under £25k to others over £200k. Comparing the size of contracts for 2015/16 and 2016/17 suggests a trend towards a reduction in contracts of under £25k, which may reflect the changing nature of advocacy commissioning as experience unfolds. While some local authorities are allocating relatively little resource to develop advocacy services, there was an indication that some are subsequently investing £150–£200k in advocacy. Nonetheless, concerns were expressed from providers about potential reductions in resources for advocacy alongside increasing demand.

    It can be difficult to interpret this data however as some local authorities were unable to differentiate spending on advocacy from Care Act overall spend and it is unclear what the per capita spend is. As one commissioner told us: 

    Our advocacy contract is a “hub” approach, bringing in all statutory advocacy provision under one contract. The contract value is £635,000 per year for IMCA, IMHA, Care Act, NHS Complaints and non-statutory advocacy. The contract specifies indicative values for the number of hours of each form of advocacy. The aim of the advocacy hub approach is to work to be flexible to meet ebbs and flows in demand, hence the indicative value approach.

    (Commissioner)

    Over half of providers (53 per cent) reported advocacy contracts with the local authority of 12 months or less. However, there was an indication that this is slowly changing: almost a fifth of providers had service contracts of three or more years and some future contracts were being planned to offer greater sustainability: 

    The contract will be for 3+2 years. That is, a three-year contract with the potential to extend for two years…This is the first time this Council has put the voluntary sector providers through a formal tendering process. Previously a lot of it was grant-funded but providers complained they had no security.

    (Commissioner, interview)
  • Number of referrals to advocacy under the Care Act Open

    Many local authorities could not easily provide numbers of people who had an advocate since April 2015. They said that this information was ‘not to hand’ or they were unable to provide an answer at this time, or simply that they did not keep such records. What was reported however, confirmed findings of earlier studies that while some areas have seen a dramatic increase in referrals for advocacy since the implementation of the Care Act, in many others rates of referral were far lower than expected. In some areas, there had been fewer than 10 referrals since April 2015, and in others over 400. 

    We found no evidence to suggest that rates of referral were linked to the model of provision.  Many providers highlighted a lack of effective training for frontline staff in local authorities as causing the low number of referrals. Ninety per cent of local authority respondents on the other hand said that frontline staff in their area had been trained. However, providers were observing variation in the number of referrals between teams working with similar client groups in the same authority.

  • References Open

    1. Department of Health (2014).
    2. AAA (2015).
    3. Local Government Association (2015). Commissioning for better outcomes: a route map.

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