Training and skills for practitioners who work with advocates
Evidence review J
NICE Guideline, No. 227
Training and skills for practitioners who work with advocates
Key theme
- Training and skills for practitioners who work with advocates
Introduction
The aim of this review is to identify the training and skills needed for practitioners who work with advocates.
Recommendations about advocacy have been made in a number of existing NICE guidelines. However, these have identified a lack of evidence relating to advocacy that would meet inclusion criteria for standard evidence reviews. Therefore, it was agreed that recommendations for this guideline would be developed by adopting and adapting advocacy-related recommendations from existing NICE guidelines, using a formal consensus based on statements generated from a call for evidence, and documents identified by the guideline committee, and informal consensus methods to address any areas of the guideline scope that are not covered by the existing NICE guidelines or the formal consensus process.
Summary of the inclusion criteria
Please see Table 1 for a summary of the inclusion criteria applied to evidence received in response to the call for evidence and identified by the guideline committee.
Table 1
Summary of the inclusion criteria.
Methods and process
The process of identifying, adopting and adapting recommendations from existing NICE guidelines, the call for evidence and formal consensus methods are described in supplementary material 1.
Declarations of interest were recorded according to NICE’s 2019 conflicts of interest policy (see Register of Interests).
Effectiveness evidence
Included studies
Existing NICE guidelines
Existing recommendations relevant to training and skills for practitioners who work with advocates were identified from 3 NICE guidelines ([PH55] Oral health: local authorities and partners, [NG108] Decision-making and mental capacity, [NG189] Safeguarding adults in care homes). The audiences for these guidelines included: people with the condition or users of a services and their families and carers; health and social care professionals, practitioners and providers; service managers; commissioners, local authorities, health and wellbeing boards and safeguarding adults boards; and other staff who come into contact with people using services (for example, housing, education, employment, police and criminal justice staff). Only NG108 and NG189 specifically listed independent advocates (with statutory and non-statutory roles) among their target audiences.
Formal consensus
A single call for evidence was undertaken for all topics included in the scope of this guideline. Additional documents were identified by the guideline committee. See the study selection flow chart in appendix A.
Four documents were identified for this review (Chatfield 2018, Lawson 2020, Newbigging 2012, Roberts 2012).
One document each focused on people living with learning disabilities (Roberts 2012), critical care unit clinicians, relatives of critical care patients and Independent Mental Capacity Advocates (IMCAs) (Chatfield 2017), people detained under the amended Mental Health Act 1983 (Newbigging 2012), and those who have duties to commission and arrange advocacy services (Lawson 2020).
Excluded studies
Formal consensus
Documents not included in this review are listed, and reasons for their exclusions are provided in appendix D.
Summary of included studies
Summaries of the documents included in the formal consensus process for this review are presented in Table 2.
Table 2
Summary of documents included in the formal consensus process.
See the full evidence tables for documents included in the formal consensus process in appendix B and a summary of the quality assessment of these documents in appendix C.
Summary of the evidence
Existing NICE guidelines
A total of 4 existing recommendations related to training and skills for practitioners who work with advocates were identified from the 3 NICE guidelines. The committee agreed 1 recommendation should be adapted and 3 recommendations should not be used in this guideline.
See Appendix F for a list of the existing recommendations, a summary of the supporting evidence behind these recommendations, and the decisions made based on the committee’s discussion of these recommendations.
The quality of existing NICE guidelines was assessed using the Appraisal of Guidelines for Research & Evaluation Instrument (AGREE II). See the results of the quality assessment in appendix C.
Formal consensus round 1
All 4 included documents (Chatfield 2018, Lawson 2020, Newbigging 2012, Roberts 2012) were assessed using the Critical Appraisal Skills Programme (CASP) tool for qualitative research. See the results of the quality assessment in the evidence tables in appendix B and quality assessment tables in appendix C.
The committee were presented with 16 statements in round 1 of the formal consensus exercise; responses were received from all 12 committee members. At the time that round 1 voting for this scope area occurred, there were 12 committee members appointed. An additional committee member was appointed between the first and second round of voting; therefore, 13 committee members were eligible for voting during round 2. Ten of these statements reached ≥80% agreement in round 1 and were included for the discussion with the committee. Four statements had between 60% and 80% agreement and were re-drafted for round 2. Two statements had >60% agreement; 1 of these was re-drafted for round 2, because the comments raised addressable issues and suggestions for revision, and the other statement was discarded.
See appendix G for the statements that were rated by the committee and results of round 1, which are provided in Table 8.
Formal consensus round 2
The committee were presented with 4 statements in round 2 of the formal consensus exercise; responses were received from 10 of 13 committee members. Two statements were combined. All statements reached ≥80% agreement and were included for the discussion with the committee.
See appendix G for the statements that were rated by the committee and results of round 2, which are provided in Table 9.
Economic evidence
Economic considerations will be taken into account together with resource impact.
The committee’s discussion and interpretation of the evidence
The outcomes that matter most
In the methods used for this guideline (adopting and adapting existing recommendations and formal consensus) no outcomes were considered formally by the committee; therefore, the committee were not required to determine which outcomes were critical or important.
The quality of the evidence
Existing NICE guidelines
The quality of the existing NICE guidelines was assessed using AGREE II. Overall, the guidelines are of a very high quality (2 or more domains scored ≥90%) and are recommended for use. Two guidelines scored lower in stakeholder involvement because there were fewer experts by experience included in the committee group compared to other guidelines. In addition, the committee considered whether the recommendation could be generalised to a new context when making a decision about adopting or adapting the recommendations, which is documented in the benefits and harms section and appendix F.
Formal consensus
The quality of all 4 documents were assessed using the CASP checklist for qualitative research. One document (Newbigging, 2012) was judged to have minor methodological limitations. The second document (Chatfield, 2018) was judged to have moderate methodological limitations because of the lack of adequate consideration for the relationship between researcher and participants. The last 2 documents (Lawson, 2020; Roberts, 2012) were judged to have serious methodological limitations because of insufficient detail regarding data collection, consideration between relationship of researcher and participants, ethics, data analysis, and recruitment strategy.
Benefits and harms
The committee acknowledged that most of these statements had been extracted from documents judged to be of lower quality. However they were in full agreement with the statements and because their own knowledge and experience chimed with the point being made they concluded it would be important to make a recommendation on that basis and that the benefits of doing so outweighed any risks of excluding the statement altogether.
Including information about advocacy in training
The committee agreed that the existing recommendation about training in applying the Mental Capacity Act 2005 and its Code of Practice (Department for Constitutional Affairs 2007) from the 2018 NICE guideline on decision-making and mental capacity [NG108] should be adapted by separating a number of points to improve readability, increase emphasis on key issues and broaden the scope of training. Further details about the committee’s decisions to adopt or adapt existing NICE recommendations in the area of training practitioners are given in appendix F. The Mental Capacity Act 2005 is one piece of legislation relevant to the entitlement to advocacy support, but entitlement to advocacy support is also covered by other legislation, such as the Care Act 2014, depending on the type of advocacy support required and the individual’s circumstances. It is a legal duty for an advocacy referral to be made when people are entitled to advocacy support and people who cannot self-refer to advocacy rely on referrals by others. However, in the committee’s experience, the complexity around the different statutory duties and eligibility criteria for advocacy makes it difficult for practitioners to understand who is entitled to an advocate. Therefore, the committee agreed it was important that health and social care practitioners receive training to help them understand who has a statutory right to advocacy support and how to request it. The committee agreed that there are circumstances where people would benefit from advocacy support that is not covered by statute (see evidence review B). Therefore, they recommended that practitioners also received training about the additional advocacy services that are locally available. The committee agreed that there are several recommendations from this guideline highlighting actions practitioners should take in order to facilitate advocacy (see evidence review E). They therefore recommended that practitioners receive training in this to help implementation of these recommendations. Furthermore, the committee acknowledged that the advocacy role is complex and varies depending on the setting and situation, for example, practitioners may need to take different actions if advocacy is non-instructed compared to when it is instructed. Therefore, the committee agreed that it was important for practitioners to understand the role of the advocate in different settings and situations so that they can understand what training is relevant to the current situation and act accordingly. The committee also agreed that in order to overcome the problem of staff turnover and to help retain organisational and individual knowledge, this training should be part of the induction and regularly refreshed. They agreed to specify every 2 to 3 years on the basis that it achieves a balance between the need to keep knowledge current and fresh in people’s minds and the time requirements and potential pressures caused by taking time out of practice for training. A number of the formal consensus statements covered training regarding different types of advocacy (statements 4 and 5), rights to advocacy (statements 4, 5, 8, 14 and 15) and how to make referrals (statements 3, 4 and 5) and were also used to inform this recommendation.
Training for staff who may be the first point of contact
Based on their knowledge and experience the committee agreed to add a recommendation about providers and commissioners ensuring that staff who may be the first point of contact understand who is entitled to advocacy and when and how to request it. In the committee’s experience this is not happening consistently and it is important that people receiving health and social care services do not fall through the gaps at this early stage.
What training should cover
Statements 1 and 11 covered providing training about advocacy for health professionals and agencies working with advocacy services. The committee agreed that this was important but that more information was needed about what should be covered by training. Health and social care practitioners should receive training about advocacy as part of compulsory induction training but, in the committee’s experience, this is very inconsistent. This can lead to misunderstanding about advocacy, poor practice, and negative working relationships. The committee agreed that making recommendations about the content of training, in order to clarify the role and remit of advocates, should help practitioners such as commissioners, social workers and members of Safeguarding Adults Boards, to better facilitate advocacy involvement and improve working relationships. The content of the training was agreed based on the committee’s experience of common misunderstandings regarding the role of advocacy. The committee agreed, based on their knowledge and experience that it was important that training included how to challenge decisions and poor practice. The committee agreed that this is a vital part of maintaining good working relationships however, this is not happening consistently. The committee also used an existing recommendation from the NICE guideline on safeguarding adults in care homes [NG189] to inform this recommendation. The recommendation from NG189 stated that all organisations involved in safeguarding should understand the role of advocacy in relation to safeguarding, think about the person’s needs and know when to refer people (see evidence review D).
What providers of training for advocacy should do
Statement 7 highlighted that people with learning disabilities should be included in leading training activities. The committee agreed that it was important that people with lived experiences of advocacy services, and not just those with learning disabilities, are involved in developing and delivering training as it provides practitioners an insight into service users’ views and experiences and could help professionals to develop a better understanding of the value of advocacy to the people they will be supporting. Furthermore, people with lived experience may have different priorities about what they think is important for professionals to know and they might have a better understanding of what gaps professionals have in practice. In the committee’s experience, including real life examples in training also has the potential to make the training more impactful and memorable, which may increase the likelihood that the training is then put into practice. The committee agreed, based on their experience, that people learn in different ways and that some people may find it easier to access training remotely, or in their own time, than attending fixed, in person training sessions. Therefore, they recommended that training should be delivered in various formats. Finally, statement 10, which emphasised that health and social care organisations should involve people with lived experience of advocacy in training sessions for health and social care practitioners, was also used to inform this recommendation. Stemming from these discussions, the committee agreed that it was important that training covered new staff, pre-registration and continuing development so that everyone is covered and there aren’t any gaps in training which could lead to inconsistent practice and referrals. The committee agreed that making recommendations about tailoring training for different practitioners performing different roles would help to ensure that the amount of training is appropriate for the role and that everyone knows their responsibilities and, therefore, increase effectiveness in practice.
Implementing the knowledge learned
In the context of these discussions the committee agreed, based on their experience, that the knowledge gained during training is not always implemented or used effectively. Therefore, they recommended that steps are taken so that health and social care providers ensure that the knowledge is being implemented in practice. The committee were aware that supervision might be one potential mechanism for ensuring that this happens, but this is currently not well structured.
Training volunteer advocates
Statement 6 covered advocacy services ensuring that any volunteer advocates they deploy are trained. In the committee’s experience, it is essential that volunteer advocates are trained, but that they also needed adequate support and supervision to help ensure consistency, and that knowledge gained during training is implemented. It is important that volunteer advocates receive the same support as paid advocates to ensure that the services provided by volunteer advocates meet the required standard. The committee agreed to move this recommendation to the section of the guideline training advocates (see evidence review I), as this recommendation is about training advocates rather than practitioners.
Statements that were not used in this review
There were a number of statements carried forward to committee discussions that were not used to inform recommendations. Statement 2 was not used to inform recommendations because the action required to address the issue was outside the scope of NICE guidelines. Statements 9 and 13 were not used because they did not include enough detail to inform what action should be taken. Statement 16 was not used because the committee agreed that it was too specific and only applied to a small number of people.
Existing recommendations not used in this review
There were a number of existing NICE recommendations that the committee neither adopted nor adapted for the section on training practitioners. The reasons behind their decision making are given in appendix F.
Cost effectiveness and resource use
Health and social care practitioners as well as other professionals who may come into contact with advocates or people who may require advocacy (including social workers, Safeguarding Adult Board members and commissioners of advocacy) should already be receiving training in legislation and in the role of advocates. Such training can be included in induction processes for the role using existing materials. This should minimise or eliminate any cost of providing this. However, refresher training is not routinely happening and there is variation across regions in how much training is tailored. While there may be some costs associated with providing refresher training, there are existing materials that can be used to facilitate training which if used would minimise cost. Further, tailoring training should also make sure resources are being used most efficiently, as not everyone will require the same depth of knowledge and amount of training reducing the time people are away from their core responsibilities.
The vast majority of the training is currently being delivered is done by advocacy organisations and does not routinely involve people with lived experience unless they are also advocates. For organisations that are not currently doing this, there will likely be costs associated with doing so as there is a need to provide support to enable some people to engage in the training and effectively share their experience with training attendees. However, this should improve the overall quality of training, making it more relevant and meaningful and help to improve the practitioners understanding of advocacy and people who use advocacy. This should lead to efficiencies through better understanding the needs and wishes of people using advocacy reducing inappropriate referrals, interventions and reducing the need to repeat meetings.
The delivery of training in a variety of formats may have some costs associated with it. However, costs will be minimal if training is performed through self-directed learning or if training is delivered remotely. Furthermore, people’s learning experience can be improved by providing training in various formats, making it more flexible and accessible. Improved training should again lead to the efficiency savings discussed above through better understanding of advocacy.
There may be some costs associated with ensuring that knowledge gained during training is applied in practice. If this was done through supervision, existing supervision frameworks and time could be used, so that no additional time is needed. However, there might be costs associated with changing attitudes and approaches used by health and social care practitioners to enable effective supervision although these should be small and short-term. There is also the possibility that increased use of knowledge in practice could lead to an improvement in the quality of services and a reduction in complaints and adverse outcomes leading to cost savings
Currently there are inconsistencies in the level and type of training provided for volunteer advocates, so there might be additional costs and resources required to provide this. However, the amount of training required will depend on the role and responsibility of individual advocates and the needs of the population in their local area. Therefore, it is not anticipated that all volunteer advocates will need training in all of the processes and areas. Training volunteer advocates is important so that the required service standard is met. There might also be savings in the long term due higher quality services and reduction in complaints.
Improved training may help identify people who have a right to advocacy under current legislation. This will subsequently increase the total number of people accessing advocacy services leading to a greater resource impact than providing training, at least in the short term. The increased access will however be from people who have a legal right to advocacy services and resources should already be in place to meet this statutory requirement. Better access to advocacy services should lead to better outcomes and a reduction in escalation of need leading to lower downstream costs and higher quality of life. This is likely to be especially true for people with a legal right where benefits of advocacy have already been acknowledged in legislation.
Recommendations supported by this evidence review
This evidence review supports recommendations 1.10.1 to 1.10.5, and 1.9.8, Other evidence supporting these recommendations can be found in the evidence reviews on who else would benefit (see evidence review B), enabling and supporting (see evidence review E), and improving access (see evidence review D).
References – included studies
National Institute for Health and Care Excellence 2018
National Institute for Health and Care Excellence (2018). Decision-making and mental capacity. Available at: https://www.nice.org .uk/guidance/ng108/resources /decisionmaking-and-mental-capacity-pdf-66141544670917 National Institute for Health and Care Excellence 2014
National Institute for Health and Care Excellence (2014). Oral Health: Local Authorities and Partners. Available at: https://www.nice.org .uk/guidance/ph55/resources /oral-health-local-authorities-and-partners-pdf-1996420085701 National Institute for Health and Care Excellence 2021
National Institute for Health and Care Excellence (2021). Safeguarding adults in care homes (NICE Guideline 189). Available at: https://www.nice.org .uk/guidance/ng189/resources /safeguarding-adults-in-care-homes-pdf-66142030079941 Chatfield 2017
Chatfield, D., Lee, S., Cowley, J., Kitzinger, C., Kitzinger, J., Menon, D. (2018). Is there a broader role for independent mental capacity advocates in critical care? An exploratory study. Nursing in Critical Care, 23(2), 82–87. [PubMed: 28247553]Lawson 2020
Lawson, J., Petty, G. (2020). Strengthening the role of advocacy in Making Safeguarding Personal, Local Government Association. Available at: https://www.local.gov .uk/sites/default/files/documents/25 .167 %20Strengthening%20the %20role%20of%20advocacy %20in%20MSP_04.pdf [Accessed 07/04/2021] Newbigging 2012
Newbigging, K., Ridley, J., McKeown, M., Machin, K., Poursanidou, D., Able, L., et al (2012). The Right to Be Heard: Review of the Quality of Independent mental Health Advocate (IMHA) Services in England, University of Central Lancashire. Available at: https://www.firah.org /upload/notices3/2012/uclan.pdf [Accessed 13/05/2021] Roberts 2012
Roberts, H., Turner, S., Baines, S., Hatton, C. (2012). Advocacy by and for adults with learning disabilities in England, Improving Health and Lives: Learning Disabilities Observatory. Available at: https://www.ndti.org .uk/assets/files/IHAL_2012-03_Advocacy .pdf [Accessed 06/04/2021] Care Act 2014
Care Act, 2014 (c. 23). Available at: https://www.legislation .gov.uk/ukpga/2014 /23/contents/enacted [Accessed 21/09/2021] Department for Constitutional Affairs 2007
Department for Constitutional Affairs (2007). Mental Capacity Act 2005: Code of Practice. Available at: https://www.gov.uk/government /publications /mental-capacity-act-code-of-practice [Accessed 15/02/2022] Mental Capacity Act 2005
Mental Capacity Act, 2005 (c.9). Available at: http://www.legislation .gov.uk/ukpga/2005/9/contents [Accessed 23/02/2021]
Existing NICE guidelines
Formal consensus
Other
Appendices
Appendix A. Study selection for formal consensus process
Study selection for scope area: Training and skills for practitioners who work with advocates (PDF, 93K)
Appendix B. Evidence tables
Evidence tables for scope area: Training and skills for practitioners who work with advocates (PDF, 247K)
Appendix C. Quality Assessment
Quality assessment tables for scope area: Training and skills for practitioners who work with advocates (PDF, 172K)
Appendix D. Excluded studies
Excluded studies for scope area: Training and skills for practitioners who work with advocates
Formal consensus (documents identified by the call for evidence and the guideline committee)
Table 6
Excluded studies and reasons for their exclusion.
Excluded economic studies
No economic evidence was considered for this scope area.
Appendix E. Research recommendations – full details
Research recommendations for scope area: Training and skills for practitioners who work with advocates
No research recommendations were made for this scope area.
Appendix F. Existing NICE recommendations
Download PDF (205K)
Appendix G. Formal consensus
Additional information related to scope area: Training and skills for practitioners who work with advocates (PDF, 170K)
Final
Evidence reviews underpinning recommendations 1.10.1 to 1.10.5 and 1.9.8 in the NICE guideline
Disclaimer: The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.
NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government, Scottish Government, and Northern Ireland Executive. All NICE guidance is subject to regular review and may be updated or withdrawn.