'When you haven't got much of a voice': an evaluation of the quality of Independent Mental Health Advocate (IMHA) services in England.

Advocacy serves to promote the voice of service users, represent their interests and enable participation in decision-making. Given the context of increasing numbers of people detained under the Mental Health Act and heightened awareness of the potential for neglect and abuse in human services, statutory advocacy is an important safeguard supporting human rights and democratising the social relationships of care. This article reports findings from a national review of Independent Mental Health Advocate (IMHA) provision in England. A qualitative study used a two-stage design to define quality and assess the experience and impact of IMHA provision in eight study sites. A sample of 289 participants - 75 focus group participants and 214 individuals interviewed - including 90 people eligible for IMHA services, as well as advocates, a range of hospital and community-based mental health professionals, and commissioners. The research team included people with experience of compulsion. Findings indicate that the experience of compulsion can be profoundly disempowering, confirming the need for IMHA. However, access was highly variable and more problematic for people with specific needs relating to ethnicity, age and disability. Uptake of IMHA services was influenced by available resources, attitude and understanding of mental health professionals, as well as the organisation of IMHA provision. Access could be improved through a system of opt-out as opposed to opt-in. Service user satisfaction was most frequently reported in terms of positive experiences of the process of advocacy rather than tangible impacts on care and treatment under the Mental Health Act. IMHA services have the potential to significantly shift the dynamic so that service users have more of a voice in their care and treatment. However, a shift is needed from a narrow conception of statutory advocacy as safeguarding rights to one emphasising self-determination and participation in decisions about care and treatment.

Conflict of roles: a conflict of ideas? The unsettled relations between care team staff and independent mental health advocates.

Drawing on a national study of independent mental health advocacy, we explored the social relations of independent advocacy. The study was commissioned by the Department of Health (England), and involved a case study design covering eight different geographies and service configurations, and interviews or focus groups with a total of 289 stakeholders across two phases of inquiry. This paper focused on the analysis of qualitative data relevant to the relationship between mental health-care services and independent advocacy services, drawn from interviews with 214 participants in phase two of the study. Discussion of these particular findings affords insights into the working relations of independent advocacy within mental health services beset by reorganizational change and funding cuts, and increasing levels of legally-sanctioned compulsion and coercion. We offer a matrix, which accounts for the different types of working relationships that can arise, and how these are associated with various levels of understanding of independent advocacy and appreciation for the value of advocacy. The discussion is framed by the wider literature on advocacy and the claims by practitioners, such as nurses, for an advocacy role as part of their professional repertoire.

Hospital--school liaison: perspectives of health and education professionals supporting children with renal transplants.

This article explores collaboration between health and education staff as a key aspect of educational provision for children with chronic medical conditions, drawing upon material from interviews with eight health professionals (paediatric nephrologists and specialist renal nurses) and 11 mainstream schoolteachers involved in the care and schooling of children with renal transplants. Notwithstanding the apparent existence of good practice, a complex interplay of attitudinal, institutional and wider political and economic factors is identified that is likely to undermine the effectiveness of collaboration between health and education professionals. The importance of hospital-school liaison - that is, of a proactive, preventative and hence systematic and strategic nature - is highlighted. Such findings have a particular relevance for policy and practice in the context of the current Every Child Matters agenda, and are likely to have wider applicability to the education of chronically-ill children at large.