Where was advocacy?

In the immediate days after Panaroma exposed the horrific abuse at Whorlton Hall, I saw a sense of shock and anger ripple through the advocacy community. Shock that this could happen (again), and anger that the safeguards meant to prevent this from happening, were so clearly missing. I received numerous phone calls, emails and tweets asking who were the advocacy provider? How the hell did they miss it? Just where was advocacy? This week we read about more failings at St Andrews hospital in Northampton. This is one of the biggest providers of private mental health care and the CQC have just placed it into special measures(1). The CQC has particularly criticised its services for young people - with the report listing one human rights abuse after another. I hear again, where was advocacy?

Before we talk about the seeming inability of advocacy to prevent these disasters in health and care, I want to take you back in time to another form of very real disaster, that of a sinking ship in Zeebrugge Harbour in 1987.

The Zeebrugge Disaster

Zeebrugge was the worst peacetime maritime disaster for the UK: nearly 200 people lost their lives after a cross channel ferry capsized and sank. After loading up cars, lorries and passengers in the port the ship had left for the return voyage to the UK with her bow doors open. In the choppy harbour, water soon rushed in and the ship was doomed. Everybody in the immediate aftermath blamed the crew for not closing the doors. Just where was the crew? How the hell did they miss it?

But when people took a step back and looked into the wider truth, they found a much more complex story. A story of systemic failings, human, cultural and technical - which made the sinking a disaster that was waiting to happen.

• Economic pressures to run the service efficiently (sound familiar?) put the crew under incredible pressure to turn each ferry around quickly. It became common cultural practice to leave with the bow doors open, closing them as they left port to save time.

• The crew had horrendous shift patterns meaning that those responsible for the critical task of closing the doors were left fatigued, exhausted and would often try to catch sleep at sea. Hmmm, unsupported and untrained staff teams - sound familiar?

• There were unclear and overlapping job roles. 2 people were actually responsible for ensuring the doors had been closed but both had assumed the other had (or was about to) complete this. This is not unlike the overlapping and confusing roles between LA, NHSE and CCG Commissioners, with everyone expecting the other to sort things out.

• Changes to the design of the ship during it’s life to improve capacity meant vehicles on the car decks could slide around the bay once water had started to enter, this disablised the ship leading to the near instant capsize. Basically the ship was not fit for purpose, Sound familiar?

The tragedy at Zeebrugge is surprisingly relevant to the current crisis facing our health and care system (and advocacy’s part in this), but the key parallel I want to draw is to caution the urge to point the finger of blame at any individual advocacy service. Instead we need to look as an entire advocacy family to deepen our understanding about what caused advocacy to be ineffective at preventing and detecting the abuse. Because the truth is there could be more Whorlton Halls out there right now, and if we’re being brutally honest, most IMHA services probably felt a sense of relief when the story broke that it wasn’t their service being shown up as lacking.

Whats going wrong with the system?

Advocacy is one jigsaw piece in a complex system which should be supporting people to live good, happy lives. Since I watched Panarama and the subsequent fallout, I wondered what exactly has to happen for torture and abuse to take place right under our noses, and not be identified? What has to fail for advocacy to be ineffective? What cultural and systemic practices have to be aligned in a specific way to make these tragedies possible? This is some of what I get to:

• Have these institutions as part of the care landscape in the first place.

• Have many of them in private hands, incentivised to make profits of up to nearly 40%(2)

• Continually strive for financial efficiency, paying minimum wage (or thereabouts) to care staff. Not investing in staff training or support. Routinely use agency staff to keep permanent staff head count low.

• Have one organisation (NHSE) fund some inpatient care, and another (LA/CCG) responsible for ongoing care in the community. Seriously, with the current crisis in social care funding is it any wonder LA’s/CCG’s are not clamouring to add more people to their unsustainable care bill.

• Place people in these institutions even when their home is hundreds of miles away. Thus making sure that the person’s family and friends can’t see them daily or casually drop in unannounced to check how they are doing. The result being to reduce and limit contact with people who are their natural allies, increasing their isolation.

• Have an ineffective regulatory body. The CQC inspection framework relies on visiting these hospitals during office hours. Why not visit in the evening or during weekends? When inspectors visit and interview patients, care staff accompany them, hovering over the patient watching every word they say. Are we really that surprised that they missed it? Oh, but wait, they didn’t miss it - an inspector raised serious concerns about Whorlton Hall in 2015 but the report was never published. It is therefore unsurpising that the CQCs current inspection approach is currently under severe scrutiny with the chief exec Ian Trenholm being forced to appear before the Joint Committee on Human Rights this week (June 12th) to answer questions about their regulation of Whorlton Hall.(3)

• Have an ineffective advocacy sector….

I hold my breath as I write these words, but yes, I think there are large parts of our sector which are currently ineffective. Not everyone and not all the time. But most of us and at least some of the time. There are reasons for this and we have to start looking at and owning these problems if we are to solve them.

Ineffective advocacy?

There is simply too much emphasis within commissioning on hours instead of impact. This breeds cultures where being busy with activity is more important than what we are actually doing. Think of your annual report - I bet there is more space given to how many people you worked with and for how long than what the advocacy achieved.

There is simply too much emphasis within advocacy on the ‘issue’ instead of the person. We see referrals in terms of ‘does this issue fall within our contract?’. We end the relationship as soon as the ‘issue’ is resolved. This is exemplified in common scenarios of the type below. A patient is detained in a hospital for more than 10 years. Does he have an IMHA? Kind of. The IMHA service knows about them and happily gets involved when there is a Tribunal or CPA. But their contract only allows them to respond to issues… they don’t see them regularly. The service wouldn’t dream of instigating a Tribunal, they don’t ask questions about discharge. They are reactive, never proactive. Tell me this isn’t familiar?

There is too much emphasis on 1:1 relationships instead of group and self advocacy. There is nothing written in any of the Codes or Guidance, that statutory advocacy has to be delivered through 1:1 relationships. Imagine the impact we could have if we were to invest some of our time and resources into group advocacy or supporting self advocacy groups. IMHAs supporting self advocacy groups - on the hospital wards - instead of running around trying to fix everything in isolation.

We don’t have strategic relationships with organisations who are the other jigsaw pieces. Sure, there will always be incredible individuals who nurture these, but as a sector, this is not something we do. Look at any CQC report. If you’re lucky it will mention if people have access to an advocate. It usually says something like ‘2 people had an IMCA’. Nowhere does it cite advocacy in terms of representing people’s experiences or providing intelligence about possible concerns. Think about your local safeguarding board - do you have a relationship where you can share systemic themes and trends about how people experience their local safeguarding team? Do you know your local HealthWatch service and work with them to flag up issues? I think the truth is we are all so busy getting on with the advocacy issue we feel we don’t have any capacity to invest in this area.

We don’t make enough legal challenges. The worst kept secret of course is our inability to challenge our paymasters. It’s so startling evident I don’t think I need to say anymore, but until we start to address this, things will not change.

And lastly, we have forgotten to admit that advocacy is hard. I am particularly guilty of this one and commit to being more truthful about the reality of what we do. I reckon there are countless times in your week when you feel out of your depth or uncertain what to do next. This isn’t a weakness and I’m certainly not being critical. But the truth is, it is often really unclear what we should do next. Last year I visited a care home with a Care Act Advocate. During the visit we heard a lady moaning for help in her room. ‘Help, help, help, help’ she cries over and over again. Instinctively I want to get up and check she is okay, but I don’t. Why? I tell myself I’m a visitor, I’m a stranger it would be inappropriate to go into her room. I talk myself out of doing anything hoping a carer will come and tend to her needs. A minute passes and no-one comes. 2 minutes pass, still nothing. After about 4 minutes a member of staff slowly saunters into her room and abruptly asks her what is the matter. He doesn’t shout at her but its not a caring tone he employs. So I am left thinking what do I do with this? My spidey senses are tingling like crazy, something isn’t right, but what do I do? It’s not safeguarding. I don’t even think it’s a complaint. What do I do? My instinct is to go back. Go back and see my advocate to ask her to keep an eye on this lady - or indeed the member of staff who has forgotten the care part of his carer title. But the advocate tells me her organisation doesn’t permit her to undertake this type of surveillance, she can only justify her time working on a specific advocacy issue.

If we want advocacy to have more impact I think we need to start talking more about these things. Let’s not kid ourselves that the advocacy we are delivering is faultless. If we want to be the good guys, if we really want to make that difference, let’s step up and take some accountability for changing how our sector as a whole operates.

Don’t blame the advocate whose job it was to shut the bow doors.

references:

(1) https://www.cqc.org.uk/location/1-121538276

(2) http://www.ianbirrell.com/shut-away-and-threatened-like-animals/

(3) https://www.cqc.org.uk/news/stories/cqc-shares-previously-unpublished-findings-2015-inspection-whorlton-hall