Should advocacy have to prove itself?
How and why commissioners choose to allocate funding to one area of activity rather than another is a bit of a dark art.
The theory, of course, is that a mix of population needs analysis, evidence of effectiveness and expressed individual wishes and needs will result in informed commissioning decisions. Personal budgets add an interesting extra dimension to how this operates. The reality, though, is often quite different to this supposedly rational process. As one commissioner recently said to NDTi, their authority’s commissioning decisions were driven by “history, government dictat and gut reaction”. You will note the absence of the evidence base from their list.
Where evidence does come into play, then my experience both locally and nationally is that it tends to be used negatively. A few years ago I used a presentation to the Seattle Research conference (sadly, for some reason, held in Newcastle and not Seattle) to explain how I had experienced the major use of research evidence in my time at the DH as being its absence creating a reason for not doing something. “If you can’t provide the evidence, then we won’t do it”.
Putting to one side how this risks stifling innovation, I have understandably heard this from local commissioners as they grapple with difficult funding decisions in a time of cuts. Faced with one choice where they have evidence of impact and another where they do not, the pressure is clearly to go with the evidence-based spend.
In this context, the publication by the School for Social Care Research of a summary of the evidence of the impact of advocacy has important implications. The core conclusion is that there is a worrying lack of evidence of the outcomes or impact of advocacy and of its cost effectiveness. It reports that most published reports are individual case studies or personal opinions that it is effective. IT describes how stories of individual success are important, but unless common themes and lessons are drawn out about how and why individuals were helped by advocacy, that ‘evidence’ is not replicable, nor properly understood and so cannot be viewed as robust evidence of advocacy’s positive impact. If the simple question is asked ‘Can we show that spending money on advocacy leads to improved outcomes for people and is money well spent’, the research evidence does not say 'yes'.
BUT, it is also really important to stress that the answer is not 'no'. There simply is insufficient evidence either way. In fact, the very small number of studies that are robust do show positive impact and cost effectiveness, but they are so few and cover such defined situations (e.g. parents with a learning disability) that general conclusions cannot be drawn from them.
Now I’m someone who has always taken the view that advocacy should be a readily available resource, open and available to people who need support to have their voice heard in difficult times. Whether that means self, peer, independent or other advocacy, it should be seen as part of the infrastructure of a local health, education and social care (and beyond) community, to ensure people get a fair deal. The government would seem to agree. One of the phrases from their health and social care reforms is ‘nothing about me without me’. (I do wonder if Andrew Lansley, when announcing that as part of his NHS changes, knew he’d stolen it directly from ‘Nothing About Us Without Us’ - the rallying call of the self-advocacy movement in the development of Valuing People).
However, there is no policy expectation that local commissioners fund advocacy as part of local infrastructure, and advocacy, information and advice are getting confused in policy terms. The nightmare situation would be if people were expected to fund advocacy out of their own personal budget. So, when faced with the care provider showing how many people they can support for an amount of money (personally I’d ask them questions about outcomes – but hey!) or the advocacy organisation saying they should be funded because of people’s right to advocacy – there is a real risk that advocacy funding will be cut further. (We know this is already happening.) Rights, as an argument, is not ‘cutting the mustard’ in the current economic climate.
What’s the answer? In some ways I think it is quite simple. Whilst big national research studies on impact would help, there is a much simpler solution. Most commissioners do not ask for evidence of impact as part of funding advocacy and most advocacy providers do not appear to collect it. By commissioner sand providers working together, it could be comparatively easy for local evidence on the impact of advocacy to be generated and the case for funding made.
I’m with those who argue that access to advocacy should be a right. Advocacy clearly has a role beyond ‘service-land’ in supporting people’s personal autonomy and position in society. However, that is not the same as saying that an organisation delivering something called advocacy has the right to receive funding without also demonstrating impact. Individual organisations need to be able to evidence that they are delivering effective advocacy and value for money, and commissioners need to be supported to demonstrate they are getting good outcomes for what they choose to commit money to. Unless the advocacy movement grapples with this, I fear for the implications in the current economic and policy climate.