Archived decisions

Contact: Paula Hallam

1. Summary

1.1 This report summarises:

· The background to the Independent Mental Capacity Advocacy (IMCA) service

· Performance and outcomes of the first year of the Hampshire IMCA service, including national comparisons and areas for development

· Expansion of the IMCA service for the Deprivation of Liberty Safeguards

· Impact and conclusions

2. Recommendations

a) The Safe and Healthy People Select Committee are asked to note and comment on the contents of this report

3. Background

3.1 The Independent Mental Capacity Advocacy (IMCA) service was introduced as part of the Mental Capacity Act 2005 (MCA) and was one of the first pieces of the legislation to come into force in April 2007. The IMCA service is intended to provide representation of the wishes and feelings of people who lack capacity, when they have no-one else to speak for them and they are having specific decisions made for them. The MCA introduced a legal duty on decision-makers to instruct advocates from the IMCA service when they are making decisions for unbefriended people about where they should live and whether or not they should have serious medical treatment. There is also a discretionary power to instruct an IMCA when there are safeguarding adults proceedings involving people who lack capacity.

3.2 The Department of Health provided each local authority area with funding to commission the IMCA service and specified that this should be done jointly with the relevant Primary Care Trust (PCT). In Hampshire, a tender process was undertaken between September 2006 and February 2007 which led to the appointment of HARG (Hampshire Advocacy Regional Group) as the provider for the Hampshire IMCA service. HARG is a consortium of advocacy schemes across Hampshire, representing a variety of geographical areas and both generic and specialist advocacy services. Each member scheme has advocates trained for this work so that there are 25 IMCAs available across Hampshire and there is a central co-ordinator who receives all referrals and allocates them appropriately. The service began on 1 April 2007 and has now been running for 18 months. The first national report on the IMCA service was published recently and the first annual report of the Hampshire IMCA service is attached at Appendix 1.

4. Performance and outcomes of the first year of the Hampshire IMCA service

4.1 Raising awareness: as the IMCA service was completely new there was much work undertaken during the first year to raise awareness about the legal duty to refer and the circumstances in which this was appropriate.

· Work was undertaken both by the providers and commissioners, through awareness raising sessions, staff training and widespread communication with relevant organisations

· Implementation of the MCA requires a certain amount of changing culture and practice and the introduction of a new and highly specific advocacy service has brought its own challenges

· For social care staff who are used to working with advocates it has meant an initially high level of inappropriate referrals because advocacy is a scarce resource and people have hoped that the IMCA service could help in situations beyond its remit

· For health staff who are generally less familiar with advocacy there has been a much lower than expected referral rate (this is reflected nationally) due to lack of knowledge of the legal duty imposed by the MCA and by a reluctance to involve advocates in medical decisions

· Both situations are gradually improving but the work to raise awareness and promote the correct use of the IMCA service will continue for the foreseeable future.

4.2 Referral rates and case studies: the annual report in Appendix 1 contains full details of referrals to the service during the first year.

· 187 enquiries were received, from which 52 formal referrals were made. The overall conversion rate from enquiry to referral was 28% but this got higher as the year went on.

· For the six months from April 2008 to September 2008, 123 enquiries have been received from which 57 formal referrals were made. The overall level of enquiries and referrals is therefore increasing and the conversion rate has improved to 46%.

· There is still more work to do but these improving figures show that awareness raising and training is having a positive effect and needs to continue.

· More importantly than the specific levels of referrals, the IMCA service is having a positive effect for the people it works with, see the section `Things that have gone well' in Appendix 1 for some case studies of individual cases.

4.3 National comparison: using figures from the first national IMCA report the tables below show some comparisons between the Hampshire IMCA service and national averages. Out of 150 local authorities, only 19 had a higher number of referrals than Hampshire, whilst 130 had less.

Age

Gender

Ethnic background

(Note there are many other categories of ethnicity, only those recorded by Hampshire were

included here for the sake of brevity)

Types of decision

Reasons for inappropriate enquiries/referrals

4.4 IMCA steering group: since the IMCA service began in April 2007, the MCA Local Implementation Network (LIN) has acted as the IMCA steering group. The LIN is a multi-agency group which meets bi-monthly to ensure that the MCA is implemented consistently and effectively across Hampshire, and is chaired by Hampshire County Council's MCA lead. The LIN receives regular reports from the IMCA service and it provides a forum for case studies and issues from the providers, commissioners and referrers to be shared.

4.5 Areas for development: the issues highlighted in Appendix 1 under the headings `Things that could have gone better' and `Things we will do differently in 2008-2009' largely mirror issues highlighted in the first national IMCA report.

· Lack of serious medical treatment referrals from acute NHS trusts - it has been difficult to arrange as many awareness raising sessions specific to the IMCA service as are really needed and this is a focus of effort in Hampshire during the current year. The Strategic Health Authority are also conducting a review of health implementation of MCA generally and there is national research being undertaken into this specific issue

· Inability to signpost inappropriate older persons referrals - this has been highlighted during the year, in the main it is possible to refer on to advocacy schemes for learning disability and mental health but there is a significant gap in provision for older people and this has been reported to the relevant commissioning team

· Adult protection referrals - when the power to instruct IMCAs for adult protection cases was introduced, local authorities were advised to put in place local criteria which was done as part of the MCA procedure in Hampshire. There have been relatively low levels of referrals for adult protection cases but the criteria about the complexity of the case have been strictly applied so that not all referrals receive an IMCA. At a recent contract monitoring meeting it was agreed to see if it would be possible to relax the criteria for older persons cases as there are no alternative advocacy services for them and with relatively few cases this should not overwhelm the service.

5. Expansion of IMCA service

5.1 In April 2009 the Deprivation of Liberty Safeguards (DOLS) will come into force. The MCA is being amended to include these safeguards so that if people who lack capacity are deprived of their liberty (apart from the Mental Health Act 1983) there is a rigorous legal system in place and there is recourse to the Court of Protection to appeal against the deprivation. The DOLS allow local authorities and primary care trusts to authorise deprivation of liberty for people in registered care homes and hospitals only, if it is in their best interests and to prevent them from harm.

5.2 The DOLS introduce additional work for the IMCA service. Firstly when someone who is unbefriended is being assessed for authorisation of deprivation, they will be referred to an IMCA to ascertain their wishes and feelings, this is very close to the existing IMCA role. Secondly anyone who is deprived of their liberty, and has a family member or friend acting as representative, can access the IMCA service for advice and support about their deprivation and appealing to the Court of Protection. Hampshire County Council is therefore currently negotiating with HARG the terms of the expansion to their current contract to incorporate the DOLS IMCA work.

6. Impact and Implications

6.1 Legal

6.1.1 Adult Services has a legal duty to commission the IMCA service and to refer to it when staff are acting as decision makers for the relevant decisions. Provided that the principles of the MCA and the code of practice are followed there is protection from liability for staff.

6.2 Financial

6.2.1 The IMCA service is funded from the MCA grant provided to Hampshire County Council by the Department of Health and additional funds have been provided from 2009-10 onwards to pay for the service required for DOLS. It is not easy to predict the demand for DOLS IMCA nor what increase there will be in demand for the existing IMCA service over time and therefore the contract for this service is kept under close review to ensure value for money and viability.

6.3 Personnel

6.3.1 There are no personnel implications for Adult Services.

6.4 Impact Assessment

6.4.1 The race and equalities impact assessment was completed for the IMCA service and is now due for review.

7. Conclusion and next steps

7.1 The Hampshire IMCA service has had a successful first year, comparable with other areas across the country. There is still a lot of work to do to raise awareness and increase referrals to the service and there are new challenges involved in taking on the DOLS IMCA work from April 2009. However the challenges are all addressed in the work plan for this and future years, so that the service should be in a good position to improve as expected from a promising beginning.

Section 100 D - Local Government Act 1972 - background documents

The following documents discuss facts or matters on which this report, or an important part of it, is based and have been relied upon to a material extent in the preparation of this report.

NB: the list excludes:

1. Published works

· HARG, Hampshire IMCA Year 1 Annual Report 2007 - 2008 (2008)

· Department of Health, The first annual report of the IMCA service Year 1 April 2007 - March 2008 (2008)

2. Documents which disclose exempt or confidential information as defined in the Act.

· None.