Nurses must understand the role of independent mental health advocates so they can ensure those detained under the Mental Health Act can access the service
Citation: Fleischmann P et al (2015) Using independent mental health advocates. Nursing Times; 111: 45, 22-24.
Authors: Pete Fleischmann is head of co-production, Social Care Institute for Excellence, London. Karen Machin is peer researcher; Michael McKeown is reader in democratic mental health; Julie Ridley is reader in applied social sciences, all at the University of Central Lancashire. Karen Newbigging is senior lecturer, University of Birmingham. June Sadd is a freelance survivor consultant based in Wiltshire.
- This article has been double-blind peer reviewed
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Nurses comprise the majority of the mental health workforce and so should be at the forefront of helping individuals make the best use of independent mental health advocacy services; to do so, they need to be better informed about the nature and value of it. Arguably, this should be an integral part of student nurse training and training supervision into registered nurse posts. This article explores what independent mental health advocacy is, the role of independent mental health advocates and how nursing staff can promote the rights of people detained under the Mental Health Act 1983 to access these services.
Underserved by advocacy
It can be confusing, distressing and frightening to be detained on a hospital ward or subject to a community treatment order (CTO) under the Mental Health Act. Feelings of powerlessness and lack of control are common, and a significant proportion of people consider that their detention under the act is neither justified nor beneficial (Katsakou and Priebe, 2007).
In 2012, a team of researchers from the University of Central Lancashire (UCLan) reviewed independent mental health advocacy services. They found that:
- Fewer than half of individuals eligible to access the services appeared to do so;
- Certain groups of qualifying patients (those eligible to access an independent mental health advocate [IMHA] under the act) were particularly underserved by independent mental health advocacy services (Newbigging et al, 2012). These are outlined in Box 1.
It is a major concern that people from these groups are likely to be the ones who most need this service. This includes people from black and Asian minority ethnic groups who have a higher prevalence of mental health issues and poorer access to services. In addition, they experience higher rates of detention in hospital and CTOs and face excessive restraint, seclusion and medication (Centre for Social Justice, 2011).
Further, the Care Quality Commission’s 2015 report found that 20% of people sectioned in hospital don’t have their rights properly explained to them.
Box 1. Populations underserved by independent mental health advocacy services
- People from black and Asian minority ethnic communities
- People with learning disabilities
- Older people with dementia
- People who have hearing impairments or are deaf
- Children and young people
- People on community treatment orders
- People placed outside of their area of residence
Source: Newbigging et al (2012)
What is advocacy?
Advocacy is taking action to help people say what they want, secure their rights, represent their interests and obtain services they need. Advocates and advocacy schemes work in partnership with the people they support and take their side. Advocacy promotes social inclusion, equality and social justice (Empowerment Matters CIC, National Development Team for Inclusion, 2014).
Independence from statutory provision is an important principle underpinning advocacy but some professionals - notably nurses and social workers - are taught that they should be the patient’s advocate, upholding the patient’s/client’s rights and promoting their involvement and participation in care and treatment (Dalrymple and Boylan, 2013).
Several international nursing regulatory frameworks promote advocacy as part of the expected nursing role, and this is often with reference to the enactment of the United Nations Declaration on the Rights of Disabled Persons (Jugessur and Iles, 2009).
However, in many situations, a professional is unable to be an advocate if they have to act against the person’s wishes or when promoting their best interests. Professionals may also have very different viewpoints about issues such as detention and treatment without consent. Therefore, it is vital that advocacy support is independent of the mental health service.
What is an independent mental health advocate?
An IMHA is a specialist type of advocate. The right to an IMHA was introduced in 2007 under amendments to the 1983 Mental Health Act. The Mental Health Act code of practice (2015) provides the context for the commissioning and provision of independent mental health advocacy services. This includes the participation of all patients in planning, developing and reviewing their own treatment and care. IMHAs have legal rights that are not automatically available to other advocates. These are outlined in Box 2.
Professionals should be aware that independent mental health advocacy does not replace other forms of advocacy or legal support, and it is not the same as independent mental capacity advocacy.
Box 2. Rights of independent mental health advocates
Unlike other advocates, IMHAs have the right to:
- Meet qualifying patients in private
- Consult with professionals concerned with the patient’s care and treatment
- See any records relating to the patient’s detention, treatment or aftercare for the purpose of providing help to the patient, where the patient gives consent
- Request access to records, if accessing the patient’s records is necessary to carry out their functions as an IMHA (Social Care Institute for Excellence/UCLan, 2015)
The IMHA role
The core purpose of the IMHA role is to protect the rights of people detained under the Mental Health Act 1983 and to provide an additional safeguard by helping eligible patients to:
- Obtain and understand information about the legal provisions to which they are subject;
- Understand the rights and safeguards to which they are entitled;
- Exercise their rights by supporting their participation in decision-making;
- Helping patients to self-advocate and/or representing them and speaking on their behalf.
An IMHA can enable service users to raise questions about their care and medication, and support them in a range of other ways to ensure they can participate in the decisions about their care and treatment, and enable them to access a wider range of care and support options. This is important because one of the underpinning principles of the Mental Health Act 1983 is that it should promote self-determination - this can involve challenging the decisions made by professionals. Benefits of IMHAs, as described by service users, are given in Box 3.
Box 3. Benefits of the IMHA service
“I had a CPA [Care Programme Approach meeting] coming up and I wanted to have support from the advocacy. I wanted to have a presence to kind of ask questions, which I thought that if she asked might [carry] more weight, if you know what I mean, if she asked the questions, because I’ve asked questions in the past and they tend to kind of answer a question with a question. So I thought if I had the advocacy present maybe I’d get a straight answer, and she asked the questions and she done a good job and we got answers to certain questions, and it went well because not too long after that I got my leave, so I think it went well.” (Service user, medium secure unit)
“I was given the number of the independent mental health advocate but I didn’t like to call. Everyone could hear my call, including the nurses. I didn’t know who I was talking to; they could be anyone, they could be agents for the staff. I was struggling with paranoia and couldn’t trust no one. I felt very alone and frightened; I watched the IMHA come on to the ward, listened to what others said about her. After several weeks, I talked with her. A few days after that, I told her about what was happening to me. She listened; I felt I didn’t have to be alone, that she could help.” (Service user)
Source: Newbigging et al (2012)
Supporting the role of IMHAs
Staff have a legal responsibility to support qualifying individuals’ access to an IMHA and it is, therefore, important that they understand this role and their legal obligations. Both managers and nurses have a responsibility to:
- Ensure they are up to date in this area;
- Be aware what advocacy services are available locally.
Nurses have numerous opportunities to promote independent advocacy services, including by:
- Making sure up-to-date posters advertising a service are displayed;
- Talking to service users about the independent mental health advocacy service;
- Contacting the independent mental health advocacy service on someone’s behalf, should they want this;
- Making a private space available where people can phone an independent mental health advocacy service in confidence.
Staff in community teams should ensure that people on CTOs know about independent mental health advocacy services. In addition, all staff should:
- Inform qualifying patients that an IMHA can be invited to ward rounds and that they can also see an IMHA privately;
- Explain the specific duties and rights of an IMHA to qualifying individuals;
- Encourage qualifying patients to speak to an IMHA directly;
- Emphasise that IMHAs are independent and provide a free service.
It may be helpful to make detainees aware of this on admission and repeat it at key pivotal points in a detention, such as before ward rounds, medication reviews and tribunals. Professionals should also be aware of the fact that younger people may feel less confident to ask about having an advocate, and some people may not notice posters on a ward.
People may have specific communication needs to do with language, learning difficulties or a lack of capacity, which must be taken into account by the IMHA service. Staff should also make sure there is a private space on the wards for users to meet with the IMHA.
A service user may need an IMHA with them in key meetings, such as care planning meetings and ward rounds, so this needs to be considered when they are being organised. The provision of advocacy can be thought of as a reasonable adjustment under the Equality Act 2010 and so going ahead with a meeting without an advocate could be seen as disadvantaging that person.
Staff can help IMHAs by responding promptly to requests for information. IMHAs may request access to medical notes. Staff should also inform IMHAs of any issues of risk each time they come onto a ward. Likewise, staff should take seriously any concerns that individuals raise through their IMHA, and respond to them promptly.
An IMHA may also raise issues they hear from more than one service user; this provides useful feedback on issues of general concern, which staff should then address.
Future development of the role
Advocacy is a means for people to have their voice heard and progress with their life; it should not be seen as a tick-box exercise (Newbigging et al, 2014). Service users may become more confident in challenging professionals’ views of what is in their best interests and, if staff share an ambition to develop more equal relationships with service users and coproduce care plans, this will be welcomed.
Improving access to independent mental health advocacy services and the quality of IMHAs are important but complex issues. Advocacy providers, commissioners, regulators, central government, mental health professionals and people who use services need to work together to ensure that everyone has their voice heard.
The Social Care Institute for Excellence and UCLan have recently developed 12 new resources in collaboration with service users and other stakeholders to improve the access to, and the quality of, independent mental health advocacy. These new resources can be accessed here.
IMHAs ensure that people detained under the Mental Health Act are aware of their rights and can support them to make their views heard. Although health professionals may try to act in the patient’s best interests, their professional duties and responsibilities may contraindicate such action. Therefore, it is vital that service users have access to an advocate, who is independent. To ensure the effective delivery of advocacy services, it is important that health professionals understand how the service works and what they should do to promote it.
- Independent mental health advocates (IMHAs) offer individuals detained under the Mental Health Act impartial support and advice
- Adhering to their codes of conduct may mean that healthcare professionals are unable to offer advice that is independent of statutory provision
- Having access to an IMHA can help patients and service users regain control of their care
- Fewer than half of eligible individuals access independent mental health advocacy services
- Nurses must understand how they can promote independent mental health advocacy services
Care Quality Commission (2015) Monitoring the Mental Health Act in 2013/14.
Centre for Social Justice (2011) Completing the Revolution: Transforming mental health and tackling poverty, Centre for Social Justice, London.
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