Commissioning and monitoring of Independent Mental Capacity Advocate (IMCA) services
Assessing the quality of the IMCA service
Commissioners will want to evidence the quality of IMCA services: both when a provider is commissioned and when it is providing the local service.
Particular challenges in assessing the quality of IMCA services include:
- The difficulty of obtaining direct feedback from service users due to their lack of capacity to make certain decisions.
- Often the IMCA role of providing a safeguard will be well satisfied without the IMCA making a significant impact on the outcome for the individual.
- The number of formal challenges raised by the IMCA service is only indirectly related to quality. For example, instigating formal challenges could be seen as evidence of an IMCA service's commitment to representing individuals but also as a lack of skills to successfully resolve issues informally.
Indicators of quality can be grouped into two areas:
1. Quality of the service provider:
- training, qualification and supervision of IMCA s
- the organisation having achieved external quality marks.
2. Quality of the IMCA service provided:
- feedback from people making instructions
- IMCA reports
- Views of people who use services
- the difference the IMCA’s involvement has made.
More information about these is provided below.
External quality marks
IMCA providers working towards or having achieved external quality marks is also considered widely to be a reliable indicator of the quality of the service. The potential quality marks include the Community Legal Services Quality Mark, Investors in People, PQASSO and ISO 9000.
A specific advocacy quality mark was launched by A4A in 2008. This was developed in response to the need for advocacy schemes to demonstrate their quality and the limited 'fit' of existing quality marks. Information about the Advocacy Quality Performance Mark can be found on A4A’s website. The quality mark now has an option for an IMCA specific review. The quality indicators used are freely available. This allows commissioners to use them directly to support the assessment of the quality of local advocacy schemes.
Feedback from people making instructions
Probably the most commonly used quality indicator is feedback from those people who instructed the IMCA service. This is widely considered to be a valid indicator of quality. Usually this takes the form of a questionnaire being sent to these people at the end of an IMCA 's work with an individual. Rates of return of these questionnaires have been a difficulty in many areas. In a small number of local authorities, commissioners have directly contacted a proportion of these people for feedback about the IMCA service. Typical questions asked include the following:
- What is the overall satisfaction rating of the IMCA service?
- Did the IMCA respond promptly to the instruction?
- Did having an IMCA make a difference to the person's views being heard?
- Did the IMCA put the service user at the heart of the decision-making process?
- Was the final report of a good standard?
- Did the report make a difference in the decision-making process?
There is a risk of a conflict of interests in relation to the decision makers' view of the IMCA service and the outcome for the service user. For example, while a decision-maker may rate an IMCA service positively for not formally challenging their decision, this does not necessarily mean that the IMCA service has been of a high quality.
Further suggestions are given in Appendix 4.
Using IMCA reports to identify quality
IMCA reports are a useful focus for identifying the quality of IMCA services. Good IMCA reports will, for example, demonstrate the following concerning the IMCA 's work:
- Understanding of both the MCA and their role.
- The work they have done to identify, support and represent the person’s views and wishes.
- The report being provided at an appropriate time to support decision-making.
A focus on IMCA reports is consistent with the common use of such reports to demonstrate that IMCAs meet the learning outcomes required for the IMCA units of the national advocacy qualification.
Commissioners may want to consider ways of sampling and quality-checking IMCA reports which do not compromise the confidentiality of individuals. There is a potential role for steering group members here. Action for Advocacy’s report writing: best practice guidance is a useful tool.
Sampling could cover the following instructions:
- Specific types of IMCA instructions, for example SMT, 39A or accommodation decisions where a move from a person's own home is being considered (see below).
- Where the IMCA has a significant impact on the outcome.
- Where formal action was initiated by either the IMCA provider or responsible body.
- Where the outcome went against the client's views (see below).
Further suggestions are given in Appendix 5.
Using service user views as a focus for quality
As identified above, there are particular challenges to collecting feedback from the service users on the quality of the IMCA service they received. It can be more useful to focus on any views they have about the outcome of the process for which the IMCA was instructed to support and represent them.
The service user’s views (including those expressed at an earlier time) can be categorised in the following way in relation to the outcome of the process:
- the outcome reflected the service user’s views
- the outcome went against the service user’s views
- service user had mixed feelings about the outcome
- not possible to establish the service user’s views.
Nationally, only in about 8 per cent of cases does the outcome go against the service user’s expressed wishes. The outcome in these situations may of course be in the person's best interests.
Focusing on these specific cases is a potential way to include the views of service users in the monitoring of IMCA services. This is because it could be assumed that, were these people to have capacity, they would be dissatisfied with the IMCA service's representation of their views.
Commissioners may want to consider asking IMCA providers to identify instructions where the outcome went against the views of the individual and to provide information about the following:
- what they did to support the person and represent their views
- what they did to ensure alternatives were considered which were closer in line with the person's views
- why they did not proceed with formally challenging the decision.
In some cases it may be possible to gain further feedback directly from the individual.
Another potential focus for quality related to client views is IMCA instructions for accommodation decisions where the person was living in their own home. The national figures identify that only a very small proportion of people in this situation had the opportunity to continue living in their home, with the vast majority moving to a residential care home. Even if the person was unable to express a view it could be the case that they would have wanted all possible support to remain in their own home. The IMCA s’ work could be examined in these cases to see if they ensured that alternatives to moving to a care home were adequately explored. This would include making full use of the opportunities of personalisation.
Further suggestions are given in Appendix 6.
Measuring the difference the IMCA service has made
There is some concern that monitoring information is too much focused on the process of IMCA involvement rather than its outcomes. One development is to look at the difference IMCAs have made to:
- how the person was involved in the decision-making process
- the outcome of the decision
- other aspects of the person’s care and support
- the practice of health and social care staff.
Looking at the difference the IMCA service makes, challenges IMCAs to consider how they can best use their time to support improvements for individuals. One way this can be done is by providing a summary of a person’s needs and wishes to a care home which someone has moved into. This could help the person receive a personalised service in the care home (see ADASS/SCIE IMCA guidance for accommodation decisions and care reviews). Looking at the difference may also mean IMCAs limiting their involvement in those cases where they may have little or no impact.
The Norah Fry Research Centre is currently undertaking research into the difference IMCAs make in this area. This may help provide bench marks for the future monitoring of IMCA services and a reliable way to compare quality between different providers.