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Independent Advocacy: A Guide for Commissioners

Section 2

Investing in Advocacy

Where are the gaps?

Is it really advocacy that's needed?

Where's advocacy needed most?

Which model would work best here?

Who is best placed to do this work?

Health Boards and local authorities have limited budgets and no shortage of demands for how to spend their money. So they need to invest astutely in advocacy.

It helps to think of investing in advocacy as a way of building community capacity, rather than simply as buying a service. Independent advocacy is not something which the local authority or Health Board could provide directly. By definition, independent advocacy operates at arm's length from, and in tension with, the formal service system.

Health Boards and local authorities fund independent advocacy because they recognise the contribution it makes to the overall healthiness and responsiveness of the service system and to wider issues of equity and inclusiveness in the community.

However, the pattern of spending on independent advocacy has in most areas been opportunistic rather than strategic. For example, advocacy schemes have been bolted on to hospital resettlement programmes for people with a learning disability because there was new money around, but with little clarity about how these schemes will continue and change after the hospital closes.

Investing wisely in independent advocacy means thinking carefully about the places where advocacy is needed, about what approach to advocacy would work best in those different places, and how public money could best be used to encourage and sustain these approaches. And - as with all commissioning - this thinking has to be done aloud and in partnership with other stakeholders. This section describes a series of stages in the commissioning process:

STAGE 1 - SET UP A PLANNING AND CONSULTATION PROCESS

Planning for advocacy is not a one-off process. Health Boards and local authorities should design and put in place a sustainable joint process for planning and commissioning independent advocacy. Some areas of Scotland have already achieved or at least started on this task.

This process must keep several elements in balance:

• Acknowledging a clear lead role for the Health Board and local authority as the responsible statutory agencies and main funders, while keeping the process collaborative and open.

• Working with the existing client-group approach to planning and managing services while developing advocacy as something wider than, and independent of, services to particular client groups.

• Consulting and involving a wide range of people, while keeping the process manageable.

• Involving existing advocacy agencies as valued and knowledgeable partners in discussions of priorities, while acknowledging vested interests.

• Involving people and groups who do not have access to independent advocacy, while recognising that this is always difficult and partial.

• Investing enough time to develop trust and collaborative working between disparate agencies while ensuring that money is spent mostly on advocacy, rather than on talking about advocacy.
  

The first step is to name and bring together lead people for advocacy in the Health Board and the local authority. Typically these lead people would have a remit to consider advocacy across 'care groups'.

Advocacy is not limited to one or two 'care groups'. Some children need advocacy - because they are seriously ill, or in care, or in trouble with the law. Some older people need advocacy. Some asylum-seekers need advocacy. Some people from ethnic minorities need advocacy. Some people who have a learning disability need advocacy. Some homeless families need advocacy. Some people in acute hospitals need advocacy. But what they need is much the same - someone to be on their side, look out for them, and help them get their point across.

The lead people in Health Boards might be people with a commissioning or planning role, or they might be part of a dedicated public involvement team. The lead people in local authorities do not have to come from social work department - they might link in to the local authority through corporate services, community education or community development. When the lead person is from the social work department, this should be from planning and commissioning rather than from operational management.

The 'right' planning area will vary between Health Board areas, and will depend as much on politics as on geography. In some areas, it will make more sense to establish a planning and funding system for advocacy across two or more local authorities.

It is essential for Health Boards rather than Trusts to take the lead in commissioning advocacy, since advocacy fits into the wider health improvement and health promotion role of the Boards. Also, advocacy agencies directly funded by Trusts tend to have less psychological independence, particularly when they are physically based on their funders' premises.

However, Trusts should be fully involved in the process of identifying and prioritising the need for advocacy. Also, on a day to day basis, Trusts will have much more contact with advocates, and will want to set up systems for working with and learning from independent advocacy. Both Acute Trusts and Primary Care Trusts should be seen as key stakeholders.

STAGE 2 - ENGAGE STAKEHOLDERS

The next step is to think through how best to involve other stakeholders. In the responses to the first draft of this document, some people stressed the importance of 'locking in' the involvement of disabled people and families at an early stage in planning advocacy. Other people wanted to ensure that the wider community was involved from the start, not just people involved with services.

In all, a very wide range of people could have an interest in and a view about independent advocacy - people who use services, family carers, professional staff, managers, GPs, local advocacy agencies, groups representing ethnic minorities, the Local Health Council, disabled people's organisations, older people's organisations, church groups, other local and national voluntary organisations.

The best way forward is likely to be a large (12-18) and diverse group of stakeholders as the core planning team, and building on to this team's work a range of additional consultation processes. Other consultation processes could include a search conference for 100 people, or having team members go off in various directions to discuss ideas with different user groups, provider agencies, and community groups.

Traditional formal meetings do not work well for most people as a method of consultation and involvement. Good consultation requires good presentation, appropriate interpreting and translation services, and good facilitation.

There is no simple formula for deciding who should make up the planning team. Invitations to join should make it clear what is being asked of people - for example, to come to six meetings over a year, to read the papers, to undertake some additional consultation within or outside one's existing constituency. Invitations should also make clear what is on offer by way of expenses and assistance for service users and carers who are part of the team. Often, getting the same people consistently is more productive than getting the ideal people occasionally.

As with any new group of stakeholders, careful attention should be paid by the advocacy planning team to the style of the meetings and the assumptions people bring. People may have different ideas about what advocacy is; they may assume that the purpose of the planning team is to decide which advocacy project gets cut; they may feel they have to use the meetings to get their own agency's view across rather than look at the bigger picture. So time has to be invested at the start for people to clarify the task, get to know and trust each other a bit, share information about what they do between meetings.

During the seminars to discuss this draft guidance, several participants stressed the value of an 'honest broker' in bringing this group together and supporting the planning process. The advocacy planning teams have two initial tasks to undertake.

Take stock of what is already provided

Where this has not already been done, the planning team should take stock of where things are now. What schemes are in existence? Who has access to independent advocacy? How much money is being spent, and by whom? (In many areas, as much is coming in from charitable funds as from the statutory sources.) There will be some judgement calls in this - for example, should part of the funding for the local Centre for Independent Living be counted as advocacy funding?

Agree principles

The planning team should agree, consult on and publish a brief joint statement of principles setting out what they mean by independent advocacy and why they think it is important. This statement provides the framework for more detailed work on priorities.

STAGE 3 - AGREE A JOINT FUNDING COMMITMENT

Local authorities and Health Boards should fund advocacy jointly. Advocacy contributes to health improvement, equity and social inclusion. It does not make sense to untangle advocacy into bits that 'belong' to health and bits that 'belong' to welfare.

Some Health Boards have argued that since they have transferred resources to local authorities to resettle people with a learning disability from hospital, they no longer have any responsibility for advocacy for this 'care group'. Similar arguments might be used in relation to older people. However, people's need for independent advocacy does not disappear when they live in a group home or their own home.

Health Boards retain a responsibility for funding and supporting advocacy whether or not they happen to have any long-stay hospitals in their area.

The statutory agencies should agree and publish an in-principle commitment of resources to independent advocacy at least over three years. This could be expressed as a percentage of overall spending.

Within this overall commitment, statutory agencies should also guarantee a certain level of core funding for at least three years to existing advocacy groups which they regard as good long-term investments. Ideally, this guaranteed funding should be provided on the basis of an independent external evaluation. This level of core funding should be enough to maintain the organisation (office, core salary and administration costs) while recognising that most advocacy agencies will secure several different specific grants to add to this core.

These two funding commitments - firstly to the sector and secondly to existing agencies which are doing a good job - will provide much-needed stability to the planning process.

Some areas have expressed an interest in setting up an independent advocacy trust to administer a single pot of money from Health Boards and local authorities. Some major funders of advocacy such as the National Lottery Charities Board and Comic Relief might be prepared to channel their advocacy funding through this trust.

An independent trust - which would have representation from statutory agencies, user-led organisations, non-government organisations, community groups and interested individuals - would be able to provide a 'firewall' between the funders and the advocacy agencies while maintaining a clear framework of accountability and audit.

Other people saw an independent trust as an unnecessary additional level of bureaucracy.

Whether or not funds are channelled through an intermediate agency of this sort, the key point is to get a joint commitment of resources for independent advocacy. The funding system should be transparent so that everyone knows where the money is going.

This contributes to trust on both sides, allows for medium-term planning and development rather than crisis management, encourages advocacy groups to manage change rather than deny problems, and supports continuity rather than the stop-start pattern experienced by many groups.

STAGE 4 - CONSULT ON, SET AND PUBLISH PRIORITIES FOR FUTURE INVESTMENT

This is the hardest part of the planning process. Even in areas with a well-developed network of advocacy groups, there are glaring gaps in people's access to independent advocacy. In the consultation on the draft guidance some people argued that advocacy should be universally available. Even if this were desirable, it is certainly not feasible within the foreseeable future.

Commissioners have to make decisions on where best to invest their limited resources. They have to balance responding to convincing proposals from existing advocacy groups with taking a strategic view of need across the whole sector. It is helpful for everyone if there is a clear statement of priorities over a three year period.

Setting priorities is a matter of values, not technology. This makes it essential for the planning team to consult with the people who might need advocacy; existing advocacy agencies, service providers and professionals from many different sectors; churches, community groups, Health Councils and others.

Search conferences and similar processes such as PATH provide a useful way to build the constituency, bring a range of views together and agree some ways to move forward. However, these processes are not well-suited to making tough decisions about money. The danger of a consensus is that the concerns of less popular groups may not be heard at all. Equally, 'random good ideas' may be agreed without much analysis.

PATH is a strategic planning tool designed to clarify shared vision and create shared commitment. It can be used with small and large groups, as well as in person-centred planning with individuals. Typically a large group PATH takes half a day and requires two experienced facilitators (a very large group may need more). The result of the PATH is a shared plan which is graphically recorded on a large sheet of wallpaper during the meeting.

Search conferencing is a way of gaining consensus and moving forward on a complex issue with multiple stakeholders. A full search conference runs for 16 hours over 3 days. Again, an experienced external facilitator is required. The process is less directive than PATH, and works very well if participants feel able to take ownership of the issue. More details on both approaches are available from SHS and the sources in the bibliography.

So commissioners and planning teams also have to rely on their own judgement and courage in setting out what they see as the priorities for future investment. Factors they take into account are likely to include:

What is at stake for people

For some people, an advocate is the difference between hope and despair. An advocate might help someone get their children back, might help someone get out of a locked ward and into their own flat, might get someone out of a nursing home where they are alone and frightened, might help someone get off the street and into a job, might help someone get what they need from a long and painful process of cancer treatment.

Some people leaving care have no-one in their life who is interested in them as a fellow human being rather than a paid professional. An advocate might help them keep going rather than give up.

For some people, an advocate is the difference between being heard and not being heard, between getting what you need and being ignored. An advocate might help someone get their point across to the GP, get their housing benefit sorted out, leave the day centre and get their own support, get access to mainstream education.

The scale and duration of the need

How many people might be in this sort of situation where they need an advocate? How long might they need an advocate for? A week? A year? A lifetime?

What alternatives to advocacy do people have in these situations?

What else is in place locally to help people in these situations? For example, perhaps there is a mentoring scheme for young people leaving care. Perhaps the assertive outreach team is doing a good job of supporting people who have a history of self-harm. Are there good generic information and advice services? What are services doing to listen better to people? How good are the care management arrangements?

The relevance of advocacy to these situations

Could advocacy make a worthwhile difference? Could it be robust enough? Are these issues which are really better addressed by improving services?

The feasibility of putting advocacy in place

Would anyone be interested in providing advocacy in these situations? Would they be capable? Perhaps there are existing agencies who could get involved in advocacy but have never thought about it. Is there an existing neighbourhood organisation which might be open to building a more formal advocacy role into its work?

There is no magic formula for working through this process. Inevitably, the planning team will be influenced by proposals which have already been put forward, some of which will have been under discussion for years. There is no such thing as a blank piece of paper. Often, the best that can be done is to make an incremental improvement, try to plug the biggest gap.

The general principle should be to keep a focus on people who are most at risk of being failed by society and the service system, and for whom the consequence of not having anyone to stick up for them are most serious, both for themselves and for society. Factors such as age, ethnicity, stigma, gender, poverty, geographical isolation, and ability to communicate are all relevant here.

The advocacy planning team should put forward and consult on some options. These could be, for example, to spend a small amount on a variety of new projects: to offer additional grants to existing agencies to extend their work into new areas; to concentrate all the new resources on one issue or on one geographical area. They should not expect consensus.

Once agreed, these priorities should be published widely, both as a stand-alone document and through other documents such as community plans and health improvement plans. The advocacy planning team should keep these priorities under review as part of the planning cycle. There may be other people whose needs for advocacy have come to light or have become more urgent.

STAGE 5 - ENCOURAGE DISCUSSION OF DIFFERENT MODELS

Once the priorities for future investment are set, the planning team needs to consider different ways advocacy could be organised. There is no one best way for all areas. When thinking through alternative approaches to providing advocacy, a number of issues will arise.

Balance between generic and specialist

Is it better to have a generic advocacy agency in one town working with all citizens at risk, or to have advocacy divided on the basis of people's disability, ethnicity, age etc.? Factors to consider here include the size and density of the population and also the existing constellation of agencies.

As one respondent commented "in my small Council, I do not see how we could go for a client-specific model". Another small Council might choose to pool its resources for one particular 'client group' with a neighbouring Council because they thought a specialist scheme would work better.

Some people argue for specialist schemes on the basis that advocates and agencies need specialist knowledge of the system to be effective. Other people argue that even where an advocacy agency is mainly providing 'expert' advocacy in relation to services, benefits and legal issues it can still serve a wide range of people well. Some respondents emphasised that some people do not 'fit' into a specific 'client group' and will lose out if all the funding is allocated on this basis.

Balance between home-grown and established/national agencies

Is it better to have small organisations rooted in the local community or larger organisations with a track record in getting things done? Or would it be worth asking a larger national organisation to get something up and running but to hand it over to community control within say three years?

Factors to consider here are: is existing service provision already dominated by one agency (in which case it would be essential to have a different agency involved in advocacy)? Could two or three agencies work together to set up an advocacy agency and thus achieve greater independence from the start? Is there generic local capacity for community development - for example the council for voluntary service?

Balance between 'expert' and 'citizen' approach

When do people need well-informed expert advocacy, and when do they need long-term person to person advocacy? For example, it may make sense to put an 'expert' agency in place when people with a learning disability are being resettled from a long-stay hospital - independent professionals who can inform and represent residents and families on legal, housing and benefit issues; but then to change to a community-based agency providing long-term citizen advocacy once people have moved.

Balance between help and self-help

When is it essential that advocates are peers - in other words they have a common experience of disability or mental illness with the people needing advocacy?

Balance between individual and collective

When could people's need for advocacy be met better by people coming together and working together rather than through individual casework?

Timing

For people with Alzheimer's disease it may be important for an advocate to meet someone and get to understand their views and needs before their ability to use language and their understanding of options diminishes.

For adults with a learning difficulty living at home with older parents, it may be important for an advocate to meet and get to know the person while the parents are still alive, both so the parents can help the advocate to get to know the person and also to give them greater confidence in the future for their son or daughter.

Location

It may be easier for advocacy schemes to have a sense of independence and project an image of independence if they are not based within the institution. On the other hand, they are more accessible both to service users and to staff if they are on the premises.

By the end of this process, the advocacy planning team will have some sketches or outlines of advocacy models. However, they will not have a detailed description or specification - and nor will it always be clear who should be providing this advocacy.

STAGE 6 - GETTING TO YES

This last stage of the process moves from a sketch for an advocacy service to a definite plan with money and people and places attached.

There are different ways to do this. Commissioners can add the detail themselves, produce a specification and put this out to competitive tender. Alternatively, commissioners can choose the agency they want to do the work, and then work on the detail together. Another possibility is to publish the sketch, and invite agencies to submit grant applications.

Some local authorities and Health Boards have used more creative approaches to developing advocacy. For example, they have used community development methods to work with local people to set up new organisations which understand the need for advocacy and which come back to the commissioners with their own proposals. Another option is to set up a grant scheme and invite applications from a wide range of groups.

In the consultation on the draft guidance, several agencies said that they were happy with competitive tendering as a way of deciding who should be funded to provide an advocacy service, while others saw competitive tendering as divisive. Some advocacy groups saw contracts as clearer and more secure than grants, while others have found the process distant and unhelpful. Some respondents argued that competitive tendering could factor in local knowledge so that smaller local organisations could still compete with large national ones.

Competitive tendering may or may not be a good way for commissioners to allocate public money to advocacy groups. However, the most important issue is what the money is used for. If the commissioners and the advocacy agency see the money as simply buying a service then the advocacy agency will take on a dependent supplier relationship with the commissioners. If the commissioners and advocacy agency see the money as a contribution from public funds towards the work of an independent agency, then the advocacy agency is more likely to think and operate autonomously.

Small shifts in mindset make a big difference. The next section is about getting this relationship right.

Section 3

Supporting Independent Advocacy

There is now a much greater emphasis on partnership between commissioners and providers of services, and a greater recognition that commissioners and planners are responsible for enabling and facilitating the work of service providers, not just negotiating and paying for it.

Advocacy agencies will benefit from support in various aspects of their work.

3.1 CONSISTENCY OF CORE FUNDING

Unlike most service providers who get paid by the volume of work they do or the number of people they care for, advocacy agencies do not have a steady income stream. Many small advocacy agencies spend a disproportionate amount of their time looking for next year's money, detracting from the quality of the work they do now and maintaining a constant sense of uncertainty about the agency's survival.

This is mostly a question of scale. Where an agency employs twenty, or a hundred, or a thousand people it can afford to have some people spending much of their time looking for grants and contracts. Where the agency employs two full-time workers, it cannot.

While it is entirely healthy and desirable for advocacy agencies to secure their funding from a number of sources - including charitable trusts and local communities - it is essential that agencies have a reliable core grant. This should run for at least three years, and be renewed for a further three years following external evaluation.

Never (or hardly ever) fund just one worker

While there are some heroic exceptions, almost every voluntary group which has just one paid worker finds it difficult to do a good job. The worker carries too many roles and too much pressure. If constraints of budget or geography mean a project has to operate with a sole worker, build in some money for external support and supervision.

3.2 DEVELOPMENT AND PROBLEM-SOLVING ASSISTANCE

As described above, initial support may be needed to get the advocacy project off the ground. This is traditional community development work - getting people together round the table and finding common cause; clarifying values, aims, methods and relationships; putting together a constitution for the group and drawing up a plan of action.

However well this initial work is done, advocacy agencies, like other organisations, start off wobbly and are likely to need some hand-holding. The period just after an organisation gets its first significant grant is usually the most difficult. Commissioners can help by being patient, by providing guidance and encouragement at difficult times, or by suggesting that groups get some external help.

Commissioners should encourage agencies to adopt and maintain good management practices, perhaps by linking them with generic agencies such as councils for voluntary service or with schemes which provide secondments from larger private or public sector organisations. Particularly where only one post is funded, it is worth budgeting for external management supervision in the early years of the project.

3.3 SUPPORT FOR CO-OPERATION, NETWORKING AND RENEWAL

Advocacy groups benefit from exchanging ideas and providing mutual support. There is also scope for more formal joint work through joint training, concerted efforts to promote advocacy locally and through jointly-managed projects.

Advocacy groups have themselves established two national networks - the Scottish Advocacy Workers Forum which concentrates on issues of professional practice, and Advocacy 2000 which is seeking to develop and strengthen the sector through evaluation, training and policy work.

Everyone benefits from some form of local networking and information exchange, but this does need to be facilitated. Where there is not already an effective local network, it is worth commissioners providing some modest funding for this through a suitable and acceptable local 'honest broker'.

The essential requirement here is acceptability; the network needs to be owned by the people/organisations involved, and they have to decide which agency they trust to take on a facilitating role.

Commissioners should also encourage advocacy organisations to spend time on renewal. Advocates, staff and management committee members need opportunities to reflect on their work, share stories of success and frustration, and re-connect with what they are trying to do. It is best to spend time on renewal when things are going well.

3.4 GETTING THE RELATIONSHIP RIGHT

Commissioners have a duty to clarify expectations and lines of accountability. It is easy to impose onerous reporting and accountability requirements on small advocacy schemes - they need the money and may agree to unrealistic targets to get it. Commissioners should encourage projects to be realistic, especially in the first year.

Monitoring and evaluation are dealt with in the next section. The general principle is not to ask for information just because. Commissioners have a duty to ensure that public money is being used well. They do not need to get involved in every detailed policy, decision or action of the agency.

Above all, commissioners should recognise that the primary accountability of any advocacy agency is to the people it serves. The agency is accountable to commissioners for how it spends public money, and should be expected to report fully on this. But commissioners do not own the agency and should do what they can to encourage the agency to maintain its psychological independence.

If commissioners seek to control the advocacy group, there is often a fierce reaction from the group which in turn irritates the commissioning agency. Commissioners should take the lead in establishing a relationship of mutual respect where both sides recognise that the other one has a valid and different role.

It is valuable to have regular meetings where the agency presents a face-to-face report on what they have been doing. This allows genuine concerns about performance to be discussed at an early stage, on the basis initially of 'what can we do to help you?'. Again, commissioners may be able to provide hands-on support or they can suggest third party agencies - for example an established advocacy group in another part of Scotland.

Commissioners should not expect the project to behave like a direct service project, and especially not like a direct service within a big structure like the NHS. Advocacy agencies are almost always close-up and personal.

3.5 TRAINING, EXPERTISE AND RESOURCES

Commissioners may be able to help or suggest local sources of help with issues such as:

• training for management committee members
• training for paid and unpaid advocates
• developing policies - for example on equal opportunities, confidentiality, recruitment and selection of staff and volunteers
• dealing with allegations of abuse
• setting up office systems and computers
• setting up systems of financial management, and providing training.

Commissioners may also be able to provide or suggest sources for premises, equipment, photocopying, graphic design, promotion/public relations etc. This may be particularly helpful in the first year.

3.6 RELATIONSHIPS WITH SERVICE PROVIDERS

Advocacy is not a substitute for accessible and responsive services. As emphasised in earlier guidance, commissioners should be encouraging service providers to improve service quality and reduce the need for advocacy. This includes for example:

• Individualised and person-centred approaches to assessment and planning with people
• Providing user-friendly information and advice
• Making services more accessible, responsive and culturally sensitive
• Recognising that patients get anxious when speaking to doctors, and that reducing this anxiety and taking time to communicate well are part of good medicine, not an extra.

Commissioners should be aware when people are needing advocates to negotiate what should be routine encounters with service system, and should raise these issues with service providers.

Commissioners are also in a position to help negotiate protocols between advocacy groups and service providers, for example on:

• access: some advocacy projects find people who need advocates simply by going into institutional settings and meeting people who are particularly isolated and at risk
  

• way to get something done? If the first channel does not work, what referrals: both sides need to be clear about who can make referrals, and what sort of information the advocacy agency needs in order to respond

• complaints: if staff in the provider agency have a complaint or a concern about the conduct of an advocate, where do they go?

• confidentiality: what can the advocate say about the person who needs advocacy, and to whom?

• access to information: who decides who can see what sort of information about a patient?

• handling conflict: where advocates are representing someone's serious concerns, what is the most constructive should happen next?

Commissioners can provide high level support and backing for advocacy. Good advocacy will not be popular with all of the people all of the time. Commissioners can explain the value of independent advocacy to people who see it as a low priority or positively unhelpful. Commissioners can help to raise the profile of independent advocacy by ensuring that it gets a mention in wider policy documents and debates. Commissioners can ensure that the role of independent advocacy is understood by staff who will came into contact with schemes and projects, by assessing training on independent advocacy.

Advocacy is not a substitute for improving service quality. Commissioners should also be looking at what they can encourage providers to do through policies, procedures, training, awareness-raising, and quality initiatives to reduce the need for advocacy. While an advocacy project may be able to help with staff training, this should not be seen as its main responsibility; and commissioners must recognise the potential for this to distract advocacy projects from their core business.

Keep support under review

Check out with local groups what support they need and want - both individually as part of the review cycle and collectively - say through an annual meeting.

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