Broadening access to Independent Mental Health Advocates

Support each other

The statutory role of the Independent Mental Health Advocate (IMHA)  grew from the 2007 amendments of the Mental Health Act in England and Wales (with a start date of 2009).  IMHAs have particular status in terms of rights to information and access that other advocates may not have within Mental Health services.  Currently commissioned by PCTS, from 2013, Local Authorities will take over commissioning of IMHA services and the right and access to good services is intended to be a safeguard within compulsory mental health services.

Last week, Community Care reported on a study conducted at the University of Central Lancashire about the use and understanding about the use of Independent Mental Health Advocates (IMHAs)  among Mental Health Professionals in England. The study has (not, I suspect, coincidently) come at a good time for the change in commissioning arrangements and a look at where things are and where they should be going.

The article itself draws attention to the conclusions that

Some professionals saw advocacy services “as challenging, even irritating and inappropriate”, the research found. One professional told researchers advocates were “amateurs meddling” and a “bloody nuisance”. Others, particularly approved mental health professionals (AMHPs), supported advocacy “but had little or no direct experience” of service users using it.

As a Mental Health Professional (and AMHP) who has had some experience of uses and referring to IMHAs, I was disappointed by this initially. Particularly the terms with which advocates were mentioned. ‘Nuisance?’, I hope so. ‘Meddling?’ well, why on earth not? Surely being a nuisance to professionals and meddling is exactly what a decent advocate should be doing – however I would find the distinction between so-called ‘mental health professionals’ and ‘amateurs’ as advocates offensive and an indication of scant respect. Respect at every level in mental health services, social services and health services has to exist.

Community Care in a blogpost have put together some of the quotes pulled from the report by social workers and AMHPs in relation to advocates which makes interesting reading alone.

My experiences have been mixed to be brutally honest. Working predominantly with people with cognitive impairments which are significant and may not be able to instruct an advocate, I’ve found our IMHAs who have come from a mental  health advocacy background, have been less than understanding of the need for non-instructed advocacy skills. I have been told following a referral I made, that they would not work with ‘Mr Brown’ because he has an advanced dementia and they were only able to do what he asked as his advocate.

I felt some of the attitudes I’ve seen by a couple of our IMHAs towards older adults with cognitive impairments have been less than positive – and I do feel quite protective towards my client group and want to ensure equal access. If only, I have thought to myself on many occasions, our IMCAs (Independent Mental Capacity Advocates) were also our IMHAs (I can’t praise our IMCAs highly enough – even (or perhaps especially) – when we disagree!).

I am always (in a nice way, of course) a little jealous of the advocates I work with. I think their job has a lot more credence than mine in some terms because while I can advocate for my clients to a point, there’s a point at which I am a part of the oppressive systems that need to be advocated against.

I understand that and respect it. I’d certainly not see advocates as any less ‘professional’ than other members of the team I work in. There has to be a distance though – which doesn’t need to stop us being friendly, personable and pleasant to each other – but does demand that sometimes we will be coming from different angles. That’s important to protect the rights of those being advocated for.

The report itself can be read here.  It explains the context of. It explains that access to an IMHA service which should be offered to everyone who is subject to a detention over 72 hours or a Community Treatment Order/Guardianship – is sparse which particular under-representation in the following areas

There was a strong consensus that those who need the IMHA service the most,access it the least. Specific groups of people that may be under-served by IMHA
services are:
 People from BME communities
 People with learning disabilities
 Older people, with dementia
 People who are hearing impaired or deaf
 Children and young people
 People on CTOs
 People placed out of area

And the issues which have coloured my own personal experiences of using IMHAs was mentioned in the report

The development of IMHA services is based on a model of instructed advocacy provided by mainstream advocacy providers. This may inadvertently disadvantage qualifying patients who have specific needs including people from BME communities, older people, children and young people and those with sensory impairments ..


There was little evidence of commissioning based on needs assessment and equality impact assessment and there was evidence in the case study sites that specific needs had not been considered. In particular, gaps were evident in relation to people from BME communities, people with learning difficulties, older people, children and young people. Further, it was evident that generally service users, particularly qualifying patients, were not being directly involved in the commissioning process or in
monitoring contracts.

So it would be unfair of me to lay the blame at the lack of capabilities of particular advocates and more on the commissioning process which sees ‘Mental Health Patient’ as a block group of people with similar needs and commissions accordingly.

The report makes a number of useful recommendations and is a good read for anyone involved and engaged in the provision of mental health services in England and Wales, whether as a professional, user, advocate, carer or commissioner.

The role of the advocate was strengthened by legislation and it is important that the benefits are not lost. I have seen such incredibly useful work done by advocacy services locally that my main gripe is that there should be an equality of access and opportunity for all who are treated compulsorily by mental health services in society.

I want more ‘nuisances’. I want more ‘irritants’. I want more challenges.

That’s what an advocacy service should be about.

pic by sparkypics at Flickr


Betraying vulnerable young people

The more I listen to the unpleasant guff that comes out of David Cameron’s mouth, the more I’m convinced that he just doesn’t get what it’s like to be poor. He and his old Etonian chums have never had to live on the breadline, and I suspect don’t know many people who have. It’s simply another world to them.

If my assumption is correct, it might go some way to explaining his latest brainspew which is a proposal to scrap housing benefit for the under 25s, on the grounds that they can just move back in with their parents if they fall on hard times.

Well, yes, that’s what people are able to do, yes? Just clear out one of the spare rooms. Maybe ask one of the servants to move out? Or perhaps let young Tarquin borow the summer retreat for a while. It’s what all the everyday folk have the capacity for, eh what?

Sarcasm aside, what on earth does Cameron think these young people will do if their parents, for whatever reason, can’t or won’t support them? Apparently the proposal will have exemptions for special cases, such as people fleeing domestic violence. No doubt people claiming such exemptions will be treated every bit as fairly as those trying to claim disability benefits.

Go to a homeless hostel? Most of them charge rent, which they expect residents to pay by claiming housing benefit. Where else are they likely to go? A cardboard box in an alleyway seems the most likely answer.

There’s been a fairly sensible response from Liam Byrne, the Shadow Work and Pensions Secretary, who points out some of the pitfalls.

This is a hazy and half-baked plan when we need a serious back to work programme for young families.

“Many young families with their first foot on the career ladder will be knocked off if help with their rent is taken away. And young families that want to work won’t be able to move where the jobs are.

“The way to get the spiralling benefits bill down is start getting young people and young families back to work.

Cameron has said that he won’t try to implement this until after the next election, presumably because the Lib Dems would be likely to hit the roof if he tried it now. Or possibly this could be a bit of mouthwash to play to his base of pig-ignorant right-wing bigots, rather than a serious policy suggestion.

Either way, if he’s saying this won’t be done until he wins the general election, you know what to do, eh?

It’s Not All About Sickness and Health


As it is carers’ week I have been reflecting on the role that carers play and I have decided to put my thoughts down. Partly because I think they might be of interest but also partly because I wanted to take some time to explore an aspect of caring that we may not always give our fullest attention to.

Caring seems to me to wrapped up in a number of powerful societal images. There is a sense of duty and stoicism about it, a classic “stiff upper lip” aspect.  Spousal carers would often use the phrase “in sickness and in health” to explain why they were offering so much of themselves to the person they were caring for. As well as the sense of duty there is an aspect of love, the powerful emotional ties felt between people who care and people who are cared for, toward the end of my Fathers life my Mothers love for him was expressed in the affection she sowed while caring for him, their intimacy and shared experience was moving and affected everyone they came into contact with, right to the very end it was obvious that here was a couple who were in love and had the roles been reversed the same would have happened. It was touching and inspirational all at the same time.

As someone who has worked with carers, had some experience of caring and now teaches others it seems this pastoral element of caring is a characteristic of our society, it seems bound up with so many altruistic, powerful notions we have came to rely on carers without being full aware of the complexity of the role they play. On the surface carers are admired for their commitment and dedication, we encourage and support them and we dedicate weeks to them. We have a deep seated respect and admiration for them. This is perhaps related to our own awareness that it is unlikely we will never have some or all aspects of this role in our life, we respect it because we know we might have to do it. We support it because it feels “right” but also out of awareness that we too will one day walk the same path.

Yet we need to also recognise that carers experience other emotions, they can become angry, frustrated, they can feel a loss of their own identity and experience a sense of their own lives, their own aspirations and desires being stymied by their role. For some they can feel resentment toward their role and this resentment can become enmeshed in their feelings about the person they care for and can spill over into their attitudes and behaviours toward the person they care for. This seems in direct opposition to the image we have of carers and we can struggle to understand how this can happen. Our image and ideas about carers are in opposition to these negative and challenging behaviours we find it hard to assimilate these opposing feelings.

As a Social Worker I always struggled with this. Reflecting on it now this struggle had two main themes. One was that I found it hard to “go there” to that place of challenging emotions, I feared that if I explored them I could inadvertently destabilise the situation and might contribute to it breaking down, there was an organisational aspect to this as well as I felt that it was important that if the situation did break down the organisation could not be seen to have contributed toward this. Secondly and most significantly was a lack of ability on my behalf to recognise that there should be nothing unusual in carers feeling conflicted, after all we all do. I love my job but there are times I become frustrated and annoyed by it, there are aspects to any situation that bring us to boiling point, finding someone to share these feelings with contributes to your ability to manage them and to feel more skilled.

For carers I have found that exploring all of their feelings is important, on many occasions I have seen carers showing a palpable sense of relief that someone is giving them permission to examine there own emotions in a non judgemental manner. Indeed I have found that carers find this kind of support as meaningful as any other and more meaningful than most. For professionals it is important that we are willing to go beyond the stereotype and populist images of carers and be willing to support carers emotionally as well as practically and socially.

Carers Week – More than Words

Building Blocks of Art
‘Carers Week’ begins today. While the ‘official theme’ of the week is ‘In Sickness and In Health’ with a focus on the health of carers, I would provide my own theme from my position of having worked in social care for a fair few years as ‘more than words’.

Carers’ need more than accolades in order to feel supported and be supported properly. We need to be able to provide resources and that needs money.

Over the last 15 or so years, there have been definite changes in the status of ‘carers’ in social care organisations.  We have rolled out ‘Carers Assessments’  and have been able to provide services for carers directly as a result of new legislation. While we  assess the needs of carers – what we don’t have and where the disconnect exists – is a duty to provide services and nor national criteria about where a service should be and must be delivered.

The problem I face all too often is revolves around carrying out Carers’ Assessments (of course there is a target for these) but not being able to actually provide anything as a result of them. To which the obvious question I am asked is ‘Why do them if they only provide information to the Local Authority?’.  My local authority, fortunately and for now, at least, is fairly generous with carer support and direct services but this is by no means universal.

Mother watches over

I have been fortunate to see and provide some excellent services through direct payments made to carers and in a lot of ways, the services I have been responsible for providing as direct payments to carers have been a lot  more successful than some of my experiences with direct payments more broadly. I am able to encourage assessments with the possibility of a direct service provision as a result but I know this is by no means universal.

Assessments in themselves can be useful if they are conducted well and sensitively. Sometimes allowing a carer to have the space to discuss their own needs and explain fully the care they are and do provide and the effects that this has on their own wellbeing/goals and lives can be valuable – however there comes a point when this has to be acknowledged in a more ‘real’ (and yes, that can mean costs) way than smiling and nodding. More than words.

I’ve also seen an increase in the ‘posting a carers assessment out’ style of assessing which can lose some of the subtleties gained in a conversation and a visit. Of course, not everyone wants an assessment because the language and the questions can be formalised and particularly we get the ‘I’m not a carer, I’m a spouse/child/parent’ response but I’d counter that’s something that can be addressed by a change in the way of ‘paper assessment’ and the language and discourse models that exist around social care. Why can’t we be more flexible regarding what an assessment actually is? Do we have to ask the questions on the form?

We give, others receive but that’s a tired model – particularly in relation to carers who give us, as a service and organisation – much much more than we can ever give them.

So why is it reduced to a paper assessment logged onto a computer database? Because that allows performance indicators to be met.

My ideal service would be more flexible about the ways that assessments are compiled and would allow much more for free text and less on box ticking. Box ticking can help some clarify but it by no means captures what role caring plays in all lives. ‘Caring’ is not uniform. There are a myriad of needs and a myriad of ways to both communicate this need and for support to be delivered – or there should be. If people want boxes to tick, by all means provide them but if they want open space to discuss or write or record what and how they feel about their role and what might help, then allow that too.

We also (in social care) need to work on our assumptions a lot. Families exist in different ways and have different histories. There may be many reasons that don’t need to be disclosed about caring may be more difficult in particular situations and assumptions can be very damaging.

The new Adult Social Care White Paper is imminent, apparently. There needs to be a commitment not just to assessments of carers but of delivery of services and support to carers. More than words.

While the government talks about ‘respite’ and the need for breaks, I’d argue that is essential but while the provision of services is being cut and there are fewer, more distant places to offer respite the realities will remain as far from the government planning as they are at present. Capital investment and investment in decent staffing in homes that offer respite consistently would help. Clear explanations about entitlements and potential costs would help. Services that speak to each other would help. Pooled budgets would help but the easy words come thick and fast. The solutions can’t be found by words alone.

The current system as it exists relies on carers significantly to ease the burden of cost of the social care system. This needs to be more transparent in terms of publishing details of how indicative personal budgets are arrived at and the amount that is ‘saved’ by a carer. If some of these ‘savings’ (not even a minute proportion – but some ) is ploughed back into effective and personalised support with professionals who are able to access and feedback good, local information and provide support and training to carers where they want it the savings over the long term would be much higher.

The cost of poor support for carers is much much higher than the cost of good support – but in these times of ‘belt-tightening’ it can be forgotten while we reach the goals of short term savings.

It’s a lesson that both the NHS and social care systems would be mindful to heed.

In order to support carers ‘In Sickness and In Health’ the government, the organisations such as the NHS and local authorities, employers and communities needs to provide ‘more than words’.

Images by W4nd3rl0st at Flickr and Sapphiren at Flickr

John Hemming MP encourages mother with history of violence to evade social services

John Hemming MP (Lib Dem, Birmingham Yardley) today made a spectacularly irresponsible and dangerous statement. He encouraged a pregnant woman whose unborn child is on the Child Protection Register, and who has a history of violence and substance misuse, to skip the country to evade social services.

There’s a story in today’s Sunday Express, of what superficially looks like one of those “politically-correct, interfering social workers” stories that the Express is so fond of.

SOCIAL workers want to seize a baby as soon as it is born because they are concerned about the mother’s violent links to the English Defence League.
Durham County Council has told Toni McLeod she would pose a “risk of ­significant harm” to the baby. Social workers fear the child would become radicalised with EDL views and want it put up for adoption immediately….

However, her cause has been taken up by Lib Dem MP John Hemming who, despite his loathing for the EDL, raised it in the Commons. He contrasts her treatment with that of the extremist Islamic cleric Abu Qatada, who was allowed to remain with his ­children when he was briefly remanded on bail earlier this year as the Government tries to deport him.

He said: “It raises a curious question as to why Abu Qatada is allowed to radicalise his children but the state won’t take the chance of allowing Toni McLeod to look after her baby in case she says something social workers won’t like.

“I am very strongly opposed to the EDL, which I believe to be a racist organisation, but I do not think we should remove all of the children of the people who go on their demonstrations, however misguided they may be.”

Mrs McLeod is reportedly considering a move to Ireland to evade the eyes of social services.

John Hemming MP has also commented today about the case on his blog.

I oppose the EDL myself. Mrs McLeod says she now does not support the EDL. My view is that the EDL are generally out for a fight rather than expressing a political position. However, I do not think association with the EDL is good cause to remove a new born child from a mother. She has no real choice but to emigrate because the care system is so orientated towards adoption.

First of all, there’s a concern here because he says, “She has no real choice but to emigrate”. He’s not saying, “Look, you should cooperate with social services, and show them that you’re a capable mother, regardless of your political views.” He’s effectively saying, “Yes, it’s okay to leg it, even though your foetus is on the CPR.”

Also, and there’s a real irony here, the Express seems to have done its homework more thoroughly than Mr Hemming. As with Mr Hemming they state that Mrs McLeod no longer supports the EDL. However, unlike Hemming, they report that she’s now believed to support the North West Infidels, an EDL splinter group that are, if anything, even worse. A couple of months ago five of their members were arrested for inciting racial hatred online. Earlier this week their leader John Shaw was jailed for neglecting his herd of llamas so badly that some of them died of starvation.

Also in the Express article (but again not mentioned by Hemming) are some snippets that perhaps paint a rather different picture of Mrs McLeod than a victim of political correctness.

Mrs McLeod, who is 35 weeks pregnant, is a former leading member of the EDL, in which she was notorious as “English Angel”. The 25-year-old has a string of convictions for violence, including butting and biting a police officer after an EDL march in 2010 and she has been banned from owning dogs after setting a pit bull on a former partner….

Mrs McLeod has posted racist abuse on social networking sites but denies being racist…

Documents seen by the Sunday Express reveal social workers are worried about Mrs McLeod’s previous alcohol and drug misuse, her “aggressive behaviour” and her alleged “mental health issues”…

Mrs McLeod’s unborn child is her fourth, all of them by different fathers, even though she’s only 25, and the first three have already been removed from her care. Still, I shouldn’t be judgemental or make assumptions about that. I’m sure she’s a perfectly good mother when she’s not biting police officers or setting dogs on people.

Mr Hemming presumably has read the Express article, since he’s linked to it from his blog. Despite all that deeply worrying information about Mrs McLeod’s behaviour, he’s happy to make a media statement enocouraging her to leave the country so social services can’t monitor her.

Well done Mr Hemming, way to put cheap political point-scoring above the safety of a vulnerable child.

The Care Conspiracy

After watching the fantastic programme last night The Men Who Made Us Fat I was struck by the similarities in the care services.  I am also reading  Bad Science at the moment so may be a bit focused upon  the interpretation of research data. I am reading this on my new eBook reader so do not consider myself to be out of touch with new technology or indeed research in the health care field. In fact I think that social networking has improved communication around health care sciences somewhat in that we can all share information much quicker now than ever before.

However, how information is shared  became quite evident in the TV programme and leaves many unanswered questions. The narrator who was very good at explaining hard science in  simple terms which is always a bonus, identified the conspiracy around the food industry and how it has influenced our health. The debate between the age old enemies of fat and sugar  actually killing us was opened up to explore the dominant research hierarchy at its best, where the good old probability factor ( that  fat or sugar  was more likely to kill us)  was  dismissed by the  food companies as being false for sugar, even though there is research evidence to say that it does us more harm.

Now I would not call myself a hard nosed researcher and being a nurse, I  have a tendency to favour the softer more qualitative research methods  but I was left wondering what if people had listened to the man who said it was sugar not fat that was killing us. What if  the food industry were not allowed to dominate the market (and the World Health Organisation which really shocked me), just like the drug companies are allowed to dominate the health care service? 

In our thirst for information  are we all being force-fed facts that are more in the interests of the businessmen than in the interests of our health and more importantly who actually cares? While the care industry is constantly being reinvented by the politicians, isn’t it time that we woke up and smelt the coffee?

Debating the Mental Health (Discrimination) Bill

13. New Members of Parliament ask questions

Yesterday there was a debate about Mental Health in the House of Commons. Although I was at work and couldn’t follow it ‘live’ but information garnered – mostly from my Twitter feed – was on the whole positive.

This was a chance for specific discussions about mental health to be discussed by our legislative assembly in an open manner and some MPs took the opportunity to talk about their own histories of mental illness.

The debate took place in the context of a Private Member’s Bill debate where  the Mental Health (Discrimination) Bill  – introduced earlier in this Parliamentary Session (after an abortive attempt last year) into the  House of Lords by Lord Dennis Stevenson and co-sponsored by Charles Walker MP , would cover four distinct and remaining discriminatory provisions in our current legal framework. It was introduced to the House of Commons by Gavin Barwell MP who ‘won’ one of the ‘Private Member’s Bill’ spots in the Parliamentary Session.

The provisions as Barwell described them himself in his speech are

To repeal Section 141 of The Mental Health Act 1983, under which a member of the House of Commons, the Scottish Parliament, the Welsh Assembly or the Northern Irish Assembly automatically loses their seat if they are detained under the Act for more than six months. There is no equivalent provision to remove an MP if they suffer from a physical illness (e.g. a serious stroke or cancer) that affects their ability to perform their role. Furthermore, a person who lacks mental capacity as defined by the Mental Capacity Act 2005 may be detained for up to 12 months and wouldn’t lose their seat.

To amend The Juries Act 1974to significantly reduce and better define who is ineligible for jury service. At the moment, the Act says that “mentally disordered persons” are ineligible. The definition of a mentally disordered person is extremely wide and includes people who manage their mental health condition via a prescription from their GP or counselling from a psychiatrist, thereby eliminating all sorts of people who would make excellent jurors. Only 2% tick the box exempting them from jury service on mental health grounds – statistically speaking many more should, so not only is the law discriminatory but it is also ineffective. Of course, someone on trial has a right to be confident that the jury is of sound mind. This Bill would seek to better define those who should be ineligible – people who have been detained under the Mental Health Act 2003, people who have voluntarily admitted themselves to hospital to seek treatment, people under guardianship or subject to a Community Treatment Order and people who lack capacity within the Mental Capacity Act 2005 – thereby making it more likely they will identify themselves correctly.

To amend The Companies (Model Articles) Regulations 2008so that a person no longer ceases to be a director of a public or private company purely by reason of their mental health. All companies are required by statute to have articles of association. The model articles operate where a company has failed to draw up its own articles and many companies who do draw up their own include most or all of the model articles. The model articles include a provision that a person ceases to be a director if a registered medical practitioner who is treating that person gives a written opinion to the company stating that that person has become physically or mentally incapable of acting as a director and may remain so for more than three months – in other words, the correct test of capacity. But there is then a totally unnecessary additional provision relating to a person’s mental health.

• To amend The School Governance (Constitution) (England) Regulations 2007 so that those detained under the Mental Health Act 1983 would no longer be disqualified from holding office as school governors. Clearly while someone is detained they will be unable to attend governors’ meetings but this may only be for a very short term and if so there is no reason why they shouldn’t resume the role.

Barwell makes the point that there is no equivalence of consideration between mental and physical health concerns in relation to recovery and this feeds into the broader stigma associated with mental health.

I suspect the stigma is related to fear about the ‘unknown’. Speaking out and identifying periods of needing support with mental health should not be something that is considered differently from other physical health needs but  there is still, I think, in some contexts, an element of seeing a mental illness as a defect of character.

If you ‘pulled your socks up’ you could see yourself through the period of depression. If you thought more logically, you would know that your anxiety isn’t rational. These are some of the common perceptions that i have come across. They can be enormously damaging as can any shift of the ‘blame’ narrative when trying to push the move towards recovery. Health – physical and mental – is something enormously personal to us. I tend to think that the two can’t be separated either. Just as we accept that people may respond differently physiologically to ‘treatment’ so we have to more broadly accept and understand there are different responses psychologically to ‘treatment’.

I’m glad this Bill looks like moving towards statute – it’s long overdue and while there is so much more that needs to be done in terms of challenging stigma – breaking down legislative and institutional barriers is a very key part to challenging and addressing stigma more broadly in the communities in which we live.

pic by UK Parliament Flickr