Quality Standards for Support and Advocacy
Work with Older People
Dr. Michael Browne. 16th October 2015.
Outline of Presentation
1. If Advocacy is the Answer, What is the Question?
2. Some Critical Considerations
3. The Six Standards and their Components
4. Some Key Challenges
What Support and Advocacy Means
• Safeguarding people’s legal rights and basic human
rights
• Enabling individuals and groups to have control over
their lives
• Helping people to know what choices they have and
the likely consequences of these choices
• At its most basic level, enabling people to tell other
people what they want
If Advocacy is the Answer, What is the
Question?
The Question, I suggest is:
• What are the components of the rights-based
Framework that underpins Support and Advocacy?
• 7 inter-related and overlapping components can
be identified
Citizenship and
Social Inclusion
Recognition
A Rights Framework for
Quality Standards for
Support & Advocacy Work
Self-realisation
Agency
Equality
Voice
Capabilities
Rights Component 1: Recognition
• The esteem that one feels based on the respect that is afforded
by others.
• Any individual needs to be able to observe and feel that s/he
has a recognised identity, experiences a sense of belonging and
is given due regard by others.
• Three spheres of recognition (Axel Honneth 2003)
(i) Primary relationships of positive regard and reciprocity
(ii) Legal recognition involving rights and duties
(iii) Each individual being able to experience valued and
respected social roles
Rights Component 2:
Citizenship and Social Inclusion
• The “umbilical connection between rights and citizenship”(Moyn
2010)
• The right of individuals “to live the life of a civilised being
according to the standards prevailing in society” (Marshall 1950)
• A redressing of imbalances in market outcomes
• Access to resources, as well as to opportunities to participate in
society
• Feelings of belonging in the broad sense of national identity
• Attachment to and engagement with neighbourhood/community
Rights Component 3: Agency
• The ability of a person to act, make choices and decisions
and express views.
• People, irrespective of their cognitive ability, need to be
able to exercise individual agency by participating in critical
decisions that affect their lives.
• Need to change from a deficits view of individual agency to
one that embraces more social, relational and collaborative
dimensions
• Expanding horizons in relation to the way people with
dementia or other cognitive impairment are to be engaged
in decision-making and choices
Rights Component 4: Voice
• The right of a person to express his/her views freely in all
matters affecting him/her, e.g.,
• Choosing where and with whom you live
• Control over one's accommodation, daily routines, activities,
and general life direction
• Opportunities at all stages of the life-cycle for participation
in valued activities
• Crucial distinction between 'decisional autonomy' and the
'autonomy of execution’.
Rights Component 5: Capabilities
• Being able to be treated as a dignified being whose worth is
equal to that of others
• Being able to love those who love and care for us and being
able to grieve at their absence
• Being able to experience longing, gratitude, and justified
anger
• Being in a position not to have one's emotional development
blighted by fear or anxiety
• Being able to engage in critical reflection about the planning
of one's own life
(Martha Nussbaum, Frontiers of Justice)
Rights Component 6: Equality
• All members of a society equally enabled to maximise their
potential.
• The needs of each and every individual are of equal
importance
“While people may differ profoundly in capacity, character
and intelligence, they are equally entitled as human beings to
consideration and respect and that when that happens, the
wellbeing of a society is likely to be increased”
(R. H. Tawney 1931).
Rights Component 7: Self-realisation
• The development of the human person in all his/her
dimensions.
• People coming to think of themselves as unique individuals
with chosen rather than prescribed or standard identities
• Being able to envision the future
• Active ‘Retirement’ Planning; Exploring alternative housing
options; Advance Care Directives, Enduring Power of
Attorney and the Think Ahead resource
Five Key Considerations
• The need for an ethical framework
• The right to self-determination
• Risk assessment and management in the context of
a rights approach
• Support and advocacy in the context of
safeguarding people who may be at risk
• Distinguishing between legal capacity and mental
capacity
The Need for an Ethical Framework
• Ethics is concerned with questions about what is morally
right in a particular situation
• In some situations, there may be several options, none of
which is unambiguously right
• Key factors to be taken into account (Nuffield Council on
Bioethics):
- A person’s wishes, values and general well-being
- Some sense of fairness or justice
The Right to Self-Determination
• Presumption of capacity
• Older persons are entitled to lead their lives
independently, in a self-determined and autonomous
manner (Council of Europe Statement on the Rights of Older Persons)
• This principle underpins the assisted decision-making
legislation
Risk assessment and management in the
context of a rights approach
• Risk assessment and management a matter of considerable
importance and has not to date received adequate attention
• The environmental context of vulnerability rather than the
individual context has been emphasised (Dr. Hoong Sin)
• Risk not simply due to disability or characteristics of the
person, but
-Related to the social and environmental context
within which a person lives and to relationships
Rights Safeguarding
• ‘Non-instructed’ advocacy but this is a somewhat contested
term
• Four distinct yet complementary approaches to advocacy in
a safeguarding role have been identified.
1.
2.
3.
4.
The Human Rights Approach
Person-Centred Approach
Watching Brief
Witness-Observer
Distinguishing between Legal Capacity
and Mental Capacity
• Legal capacity is conceptually very different from mental
capacity
• Legal capacity is the ability to hold rights and duties (legal
standing) and to exercise these rights and duties (legal
agency)
Mental capacity refers to the decision-making skills of a
person, which vary from one person to another
(UN Committee on the CRPD).
• ‘Term ‘mental capacity’ in the Assisted Decision-Making
(Capacity) Bill 2013 changed at Committee Stage to
‘decision-making capacity’.
The Six Quality Standards
1. Respect
Reflecting the right of every person to be treated with dignity,
including each individual’s right to privacy, confidentiality and
self-determination.
2. Social Justice
Promoting equal treatment with other people in respect of
access to basic goods, services and protections and a positive
affirmation of social solidarity.
3. Competence and Compassion
Demonstrating high levels of skill, competency, compassion
and consistency on the part of advocates.
The Six Quality Standards
4. Accessibility
Support and advocacy available in a manner that is
convenient and easily accessible to people who require it.
5. Independence
Structurally, operationally and psychologically independent
from health and social care service providers and representing
only the will and preferences of people receiving support.
6. Accountability
Acting with integrity and responsibility and engaging with
people who use the service and with other stakeholders in an
honest and transparent manner.
What the Standards Provide
• An outline of best practice in providing support and advocacy
• A vision for support and advocacy work based on sound principles
• A value-based benchmark against which the functioning of advocacy
providers and the practice of advocates can be measured;
• An identification of best practice in respect of enabling individuals to
exercise their will and preferences in accordance with people’s basic
right to self-determination;
What the Standards Provide
A menu of support actions:
(a) To empower people to articulate their needs and have their
voices heard, and
(b) To safeguard the rights of individuals who are vulnerable for
one reason or another
What is Included in the Section on
Standards
• The Six Standards
• Four Components under each Standard
• What is Expected from Advocates under each Component
• What is Expected from Advocacy Providers under each Component
• Expected Outcomes for people who use the Support and Advocacy
Service under each Component
• Indicative Evidence of Compliance for each Standard (Supporting
Policies and their Practical Application)
(SAGE has detailed policies and operational guidelines)
Respect: The 4 Components
• People treated with dignity and respect in all interactions
• People’s autonomy and right to self-determination
protected
• All personal information, whether obtained directly or
indirectly, treated in strict confidence
• Empowerment of individuals a core value
Social Justice: The 4 Components
• An underpinning human rights perspective in all
engagement with people
• A focus on social inclusion
• Each person recognised as having equal rights before the law
• Recognition of and respect for diversity
Competence and Compassion:
The 4 Components
• Advocates adequately trained, supported and
supervised in their work
• Adherence by Advocates to agreed Codes of Practice
• Advocates working consistently to high quality
standards
• Total clarity of advocacy role and boundaries
Accessibility: The 4 Components
• Service available in a timely and equitable manner
• Service promoted so that potential users are aware of it
• Proactive in seeking out hard-to-reach people and those
who might have difficulty self- referring
• Information about the service fully accessible to all groups
and individuals
Independence: The 4 Components
• Service structurally and operationally independent
• Advocacy providers and advocates free from conflict of
interest
• Clear boundaries between advocates and health/social care
services staff
• Collaboration by advocates with other health/social care
providers
Accountability: The 4 Components
• The Support and Advocacy Service accountable to the people
who use the service
• Service effectively managed and transparent governance
structures in place
• Adherence to all legal requirements
• Underpinned by human rights provisions and equality
legislation
Integrating Independent Support
and Advocacy: What is Required
• Policies and practice that respects the rights of people
individually and collectively
• Integrating an ethos of independent support and advocacy
within the health/social care setting
• Acknowledging the importance of rights safeguarding
• Understanding the multiple roles of advocates
• Entering into a Service Agreement/Memorandum of
Understanding with an Advocacy Provider
• Having a particular focus on people who may not be able to
self-refer to advocates
Five Case Scenarios
• A person being discharged from an acute hospital wishing to
live at home
• A person in a nursing home getting access to his social
welfare payment
• A person living in the community needing support to protect
his rights
• A person transferring from an nursing home to an acute
hospital
• A person with dementia living at home with a relative.
What the Case Scenarios Show
• How the Quality Standards apply in different
situations and contexts
• The complexity of the support and advocacy
process
• The need for a systematic and balanced approach
by the advocate
• The need to take full cognisance of people’s basic
rights and to facilitate their will and preferences
Concluding Comments
Need for a Change in Narrative:
• From tokenistic gestures towards people’s rights to full
legal and institutional protection of those rights
• From people with dementia as a group/category to
individual personhood as a central tenet/core value
• From older persons as a specific identity group to
vulnerability across the life-cycle
A New Narrative
• From minimum standards in service provision to
enhancing quality of life across all life domains
• From sectional interests to intergenerational
solidarity
• From benevolence to justice
Re-configuring the Narrative
“By questioning past practices and by revealing present
practices, we cause a shift or a tremor and draw attention to
‘what could or should be’ (Moira Gatens 2004).
These Standards can help to progress the ‘what could or
should be’ agenda.
‘If Advocacy is the Answer…
…..What is the Question?’
While Advocacy and has a significant role to play,
and while these Standards can help in that regard,
it is almost certain that:
The question remains as important as the answer.
SAGE and other similar organisations have a crucial
role to play in continuing to ask that question.
Values, Standards & Law
“Too often we see the issues
facing older people as related
solely to health and social
care. In doing so we can
sometimes forget the
fundamental importance of
values, standards and the law
in determining the wellbeing
of citizens”
Mary Laffoy. Judge of the Supreme Court
October 2015
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