10 Top tips for commissioners: Commissioning Independent Mental Health Advocacy (IMHA) services in England

Published: March 2015

Key messages

Introduction

This briefing aims to support local authority and health service commissioners to commission good quality IMHA services in the light of recent changes to commissioning arrangements. Under the Health and Social Care Act 2012, responsibility for commissioning IMHA moved to local authorities. This came into force in April 2013.

The commissioning of IMHA is taking place in a complex environment. There is a challenging economic climate, in which commissioners need to support good quality services as well as make savings. In addition commissioning IMHA requires joint working between local authorities, mental health service providers and other partners.

While approaches to commissioning IMHA services have become more systematic since its introduction in 2009, commissioning based on needs assessment and equality impact assessment is still rare. People who use services, including qualifying patients, are often not directly involved in the commissioning process or in monitoring contracts.

The importance of effective commissioning

Effective commissioning is essential to the development of good quality IMHA services that meet the needs of people 10 Top tips for commissioners who use them. It plays a central role in driving up quality, facilitating integrated service delivery and making the best use of resources to deliver better outcomes for IMHA partners.

10 Top tips

The following 10 top tips are designed to help commissioners develop good quality IMHA services that meet people’s needs. They are not meant to be an exhaustive list but highlight key areas you should consider in the commissioning process and in developing service specifications.

Role and responsibilities of IMHA

1. Understand the role and responsibilities of IMHA and other forms of advocacy.

Commissioners need to be knowledgeable about and understand advocacy, in particular the IMHA role, and the duty to provide IMHA which was introduced in 2007 following amendments to the 1983 Mental Health Act.

IMHA services were introduced to safeguard the rights of people detained under the Mental Health Act (referred to as ‘qualifying patients’). IMHA services aim to enable people to understand their rights and safeguards under the Mental Health Act, and to participate in decisions about their care and treatment.

An Independent Mental Health Advocate is a statutory role, with specific responsibilities.

These include:

• Supporting qualifying patients to access information and to better understand what is happening to them.
• Supporting qualifying patients to explore options and to engage with decision-making about their care and treatment.
• Supporting qualifying patients to articulate their own views.
• Speaking on the qualifying patient's behalf, as instructed by them, and representing them when requested.
• Accessing records relating to the qualifying patient’s detention, treatment or after-care.
• Providing non-instructed advocacy to qualifying patients who cannot clearly instruct their advocate or lack capacity to make specific decisions.

People are eligible to use IMHA services in England if they are:

• detained under the Mental Health Act 1983 (excluding people detained under certain short term sections (4, 5, 135, and 136)
• conditionally discharged restricted patients
• subject to guardianship
• subject to CTOs.
• informal patients who are being considered for treatments requiring consent and/or a second opinion also qualify for IMHA. This includes people aged under 18 years who are being considered for electroconvulsive therapy (ECT).

Co-production

2. Take a co-production approach to commissioning, which fully involves people who use services and carers.

Commissioners should:

• Put systems in place to enable people who use services and carers to participate in commissioning in a meaningful way.
• Involve people who use services and carers in the design development and monitoring of IMHA services.
• Involve people who use services (including current or former IMHA partners) and carers in the commissioning and tendering process.
• Provide appropriate ongoing support to enable co-production in commissioning.
• Ensure there are methods in place to enable IMHA partners to provide feedback on their experience to commissioners.

Strategic needs assessment and asset mapping

3. Develop IMHA services that meet the needs of local communities by conducting population needs assessment and an equality impact assessment

Commissioners should:

• Conduct an annual local needs assessment, which takes account of demographic factors, such as:
  • higher rates of detention under the Mental Health Act of people from BME communities
  • the number of people who might benefit from non-instructed advocacy
  • geographical factors
• Pay particular attention to the availability of provision of IMHA for:
  • children and young people
  • older people
  • people from BME communities
  • People with learning difficulties, physical disabilities and/or sensory impairments.
  • Lesbian Gay Bisexual and Transgender people
• Invest in IMHA services that reflect local needs and demands as established through the population needs assessment.
• Ensure that there are sufficient IMHAs to meet assessed need and potential demand.

Outcome-based commissioning, quality and cost

4. Develop IMHA services that deliver meaningful outcomes for IMHA partners.

Commissioners should:

• Require advocacy organisations to demonstrate the difference IMHA makes for individuals and communities.
• Develop meaningful outcome measures in partnership with people who use services, IMHA providers and carers.
• Ensure outcome measurement addresses the self-defined outcomes of IMHA partners.
• Monitor IMHA services on specified outcomes of IMHA provision.
• Associate outcomes with the key role and purpose of IMHA.
• Be aware of views of people who use services, including complaints, feedback and commendations on the quality of IMHA services.
• Be up to date with current research around best practice in the provision of IMHA.
• Be knowledgeable about national standards and quality indicators relating to the provision of IMHA.
• Invest in IMHA services in a sustainable way.
• Invest in adequate infrastructure costs (for example, to cover training, support and staff development).Include in contracts with mental health providers requirements for them to provide a supportive operating context for IMHA services.

Meeting diverse needs

5. Work with individuals and groups from marginalised communities to ensure that IMHA services are culturally sensitive and diverse.

Standard approaches to service delivery can limit the ability of IMHA services to respond to people’s needs in culturally sensitive ways. People from some communities may perceive IMHA services as discriminatory or unsafe, leading to their reluctance to engage.

The 2015 Mental Health Act Code of Practice says that local authorities should ensure that IMHAs understand equality issues and that there are sufficient IMHAs with a specialised understanding of the needs of particular groups.

This means commissioners should take the following into account when drawing up tenders, service specifications and contracts for IMHA provision:

• Ensure that IMHA services meet diverse local needs.
• Undertake equality impact assessments of IMHA service specifications.
• Encourage IMHA services to develop and maintain networks and positive working relationships with groups representing people from diverse communities.
• Invest in capacity building of community organisations that represent diverse communities so that they can deliver IMHA services.
• Take account of the views and experience of community organisations with knowledge of the needs of people from underserved communities.
• Ensure that availability and access to IMHA is monitored across all equality groups on a regular basis.
• Analyse data about uptake to ensure that IMHA provision is non-discriminatory and meets the diverse needs of qualifying patients.
• Encourage IMHA services to employ specialist workers who can meet the needs of the local population.
• Ensure there is sufficient access to interpreters and training for IMHAs to work with interpreters.
• Expect IMHA services to provide access to equalities and diversity training for IMHAs.

Engaging with IMHA providers

6. Work with IMHA services to ensure that IMHA provision meets the needs of IMHA partners.

This means commissioners should:

• Hold provider events as part of the procurement process for IMHA.
• Encourage providers to think creatively about how to deliver IMHA services.
• Ask questions during the tender process that elucidate the ethos of potential IMHA providers.
• Hold regular contract meetings and maintain dialogue with IMHA providers.
• Regularly consult with IMHA providers and IMHA partners to hear their concerns.

IMHA and other forms of advocacy

7. Support a whole systems approach to advocacy, linking IMHA to other forms of advocacy to ensure continuity of support to IMHA partners.

IMHA and Independent Mental Capacity Advocate (IMCA) services are statutory forms of advocacy. The role of IMCA is to support and represent people deemed to lack capacity in important decisions about serious medical treatment and changes of residence as specified in the Mental Capacity Act 2005. People qualify for IMCA when there is no-one else suitable to support them. Some people who qualify for IMHA might also qualify for IMCA. In addition as a consequence of the Care Act 2014, from April 2015 there will be a new right to independent advocacy to support people who satisfy specific criteria with social care assessment, planning, safeguarding and appeals processes.

Non-statutory forms of advocacy include generic mental health advocacy, peer advocacy and citizen advocacy. There is no legal obligation for local authorities or other agencies to provide these types of advocacy, though evidence shows they support wellbeing and bring about positive outcomes for people who use mental health services.

The provision of other forms of advocacy enables a holistic approach to peoples’ needs, increased service flexibility and better outcomes.

Commissioners should ensure that:

• IMHA provision is linked to the provision of other forms of advocacy, including:
  • generic (or non-statutory) mental health advocacy
  • IMCA ◦ specialist children’s advocacy services
  • self-advocacy
  • peer advocacy
  • independent advocacy under the Care Act 2014
• IMHA provision recognises the potential need for continuity of advocacy when a person no longer qualifies for IMHA, or when there is a transition between services on the basis of age or other factors.
• IMHA services are knowledgeable about peer support and other userled initiatives that promote selfdetermination, and facilitate access to these initiatives.

Non-instructed advocacy

8. Ensure that IMHA services offer both instructed and non-instructed IMHA to meet the needs of those unable to tell the advocate what they want, such as older people with dementia and people with severe learning difficulties.

Commissioners should ensure that:

• IMHA providers offer both instructed and non-instructed advocacy.
• A policy is agreed with the provider about the use of non-instructed advocacy.
• IMHAs receive training in using non-instructed advocacy.
• IMHAs are able to produce noninstructed advocacy reports.

Out of area placements

9. Make arrangements for IMHA for people placed in hospitals outside their area of residency.

 

The local authority for the area in which the hospital is located is responsible for commissioning IMHA for patients who are placed there but are not normally resident in that Local authority. Qualifying patients placed out of area experience difficulties associated with service continuity.

Commissioners therefore need to:

• Be aware that responsibility for commissioning out of area IMHA provision is with the commissioner where the person is placed.
• Local needs assessments should take account of out of area placements.
• Clarify arrangements for IMHA provision for people placed out of area to ensure that they are in line with the Health and Social Care Act 2012.
• Fund IMHA services for all qualifying patients in their area, including people who are not ordinarily resident in their area.
• Develop joint agreements and protocols with stakeholders involved in the provision of out-of area placements.
• Establish reciprocal arrangements with other commissioners in other local authorities.

Links with health service commissioners

10. Work with health service commissioners to ensure effective IMHA delivery

Local authority commissioners need to:

• Work in partnership with health service commissioners in CCGs and specialist services to provide the necessary conditions for the successful operation of IMHA services.
• Develop agreements with CCGs and secure hospital commissioners about sharing concerns and other appropriate intelligence about the quality of IMHA provision.
• Contribute to clarifying the interface with specialist commissioning for IMHA provision by national specialist services.
• Feedback to health service commissioners intelligence about the quality of mental health services from a summative analysis of outcomes for IMHA partners and issues raised by IMHA services.