Vision and reality
Is independent mental health advocacy working for black and minority ethnic service users? asks Marcel Vige
Article from Openmind 160, November/December 2009
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The recent amendment of the 1983 Mental Health Act is particularly significant for black and minority ethnic (BME) communities, given the entrenched association between ethnicity and compulsory detention under mental health legislation. Independent mental health advocacy (IMHA) – statutory advocacy provided to patients subject to certain aspects of the Act  – is in some ways a response to this. It is an attempt to make the operation of the Act more responsive to those subject to its powers – particularly African-Caribbean people, who are still the group most likely to be sectioned. 
The need for advocacy throughout the sectioning process was a central finding of the race equality impact assessment on the proposed changes to the 1983 Act carried out by the Department of Health. Government spokespeople have referred specifically to the role of IMHA in addressing this recommendation.  So it is critical to ask whether IMHA in its current rollout does actually address the needs of BME service users.
Advocacy helps people to access and navigate health and other systems. Most advocates also see their role first and foremost as representing the views and priorities of their client, particularly where their client is subject to the decisions of other professionals. Inevitably this means that advocacy provision will vary according to the needs and perspectives of those accessing it.
The myriad forms of advocacy reflect this, not least those that have emerged within BME communities.  These tend to be more rights based, with less clear-cut distinctions between what might be seen as advocating and befriending. They are also less domain specific, instead covering a range of heath, social care and welfare issues. Such forms of advocacy reflect particular understandings and ways of communicating and engaging, all of which vary across ethnic/cultural groups. IMHA needs to be able to incorporate this variety of styles and approaches if it is truly to provide culturally appropriate support.
There are concerns that the IMHA model as a whole is too formulaic and that cultural responsiveness is a ‘bolt-on’ rather than a fundamental part of the approach. The IMHA code of practice does give basic examples of what culturally responsive advocacy might look like. However, there is no detailed guidance on how such services are to be developed. A commissioning process is needed that requires those bidding for IMHA contracts to spell out how they will ensure appropriate provision to BME groups. Their responses should determine whether bids are successful.
As a statutory service IMHA is subject to all the managerial and administrative demands that go along with statutory contracts. As many BME advocacy providers are smaller scale grassroots organisations, they are less able to meet such requirements. There may well be a commitment on the part of larger, non-specialist providers to provide quality services to diverse communities. However, the expertise, community connections and styles of engagement are unlikely to be as sophisticated as those of advocacy providers who have grown out of particular communities.
There is also the risk that IMHA becomes ‘the only game in town’, attracting scare funding which is then denied to other forms of community-based advocacy. Again, this could threaten the grassroots community-based approaches of many BME advocacy organisations.
So what is to be done? One way of addressing these issues would be to up-skill BME organisations, putting them in a better position to bid for IMHA contracts. For some, this might mean simply training staff on the operation of IMHA; others might require support to improve managerial or administrative systems. Although this might seem like favouring BME organisations in contract bids, in effect it would equal the playing field. BME advocacy providers would be able to compete for contracts on a par with larger-scale providers.
Another solution would be to encourage collaborative bids between advocacy providers. This could generate various forms of delivery, such as locating IMHA within the BME service while maintaining a reporting/supervisory relationship with the larger provider administering the IMHA contract. In this way the IMHA would have the expertise and, where possible, the working style of the BME service, while benefiting from the infrastructure and support systems of the larger organisation. There would also be added benefits in terms of an exchange of knowledge between providers, and a revenue stream for BME service providers. The larger advocacy provider would also benefit from being better able to serve the needs of diverse communities, thereby fulfilling the requirements of the IMHA code of practice. Although Mind and others argued for this kind of arrangement throughout the development of the IMHA model, the approach was ultimately dropped by the Department of Health.
IMHA began in April 2009, so it is still in its early days. In principle, providing advocacy to people subject to detention and compulsory treatment under the Act can only be a good thing. In terms of BME communities, the framework for effective provision is clearly reflected at a policy level. Unfortunately, this has not translated into practical impact on the development and delivery of services.
In the absence of a strategy to address these issues built into all aspects of IMHA, providing culturally appropriate services falls to individual contract holders, the majority of whom are not embedded within BME communities. Although local Mind service providers and others are pursuing partnership/collaborative approaches, the absence of a consistent approach across all IMHA providers remains a massive deficit.