I remember having to write an essay about the Mental Capacity Act (MCA) during my undergraduate years; yet it took me over a year in practice to fully understand it's relevance and how to use it...

Since working within the community dental setting and treating special care patient groups, I find myself referring to the Act almost every day!

The Act, passed into law in 2005 and all health professionals have to follow its Code of Practice when treating patients - in particular this could be in those who may have a cognitive impairment or learning disability, I find most commonly I use the act when treating patients who suffer from dementia. 

According to the act, someone who lacks capacity to consent cannot:

1. Understand the information relevant to the decision
2. Retain that information for sufficient amount of time
3. Weigh up that information as part of making the decision
4. Communicate this decision

If you work in a trust or other hospital or community environment, it's likely they will have their own trust policy on MCA that you should follow. We also have additional paperwork to fill in (a template framework) which is very useful, as well as additional consent forms for those who lack capacity to consent for themselves. If you work in practice, this may not be available to you. In these cases here are some of my tops tips.

• Do not assume someone lacks capacity. This can be tempting if a patient attends with their carers or family, but try to engage them in the decision making process
• Break things down into simple stages and reintroduce these at the beginning of appointments (this can be particularly useful for dementia patients or those with learning disabilities). Don't overwhelm them with information in a short space of time
• Information may have to be delivered in several formats, especially if there are sensory difficulties. For example, verbal, written (large print or with illustrations) or the use of an advocate/interpreter
• The environment you are in may affect the ability for a patient to have capacity e.g. familiar settings, the same surgery or staff, or even treatment in the domiciliary setting may help 
• Take into consideration time of the day; early morning appointments may mean a patient is less disorientated
• You may need to take opinions of other individuals into account when making a best interest decision e.g. carers, family members, other professionals, Powers of Attorney (POA)
• There are 2 different POAs: Health and Financial. Even if the patient has a health POA, they still cannot consent on a patient's behalf but can input their opinion when making decisions 
• In our service, if things are relatively simple e.g. an unrestorable and symptomatic tooth requires extracting, 2 dentists will sign the appropriate consent form
• If things are a little more complex, a best interests meeting will be set up with the patient, more than one dentist, if there are available the patient's carers/family members/POAs and if necessary an Independent Mental Capacity Advocate (IMCA).
• Record keeping is key in this case and always be mindful of any safeguarding issues. 

If you are still unsure or don't feel confident in these cases, consider referring these patients onto the your local community dental services as we are experienced in managing these cases. 

For more information, see the Mental Capacity Act.

I hope this clarifies things! Do you find yourself using the MCA in practice? What do you find challenging? Let me know in the comments below!

Newly qualified Dentists like myself are facing some shocking statistsics nowadays: in a recent talk by Raj Rattan we were told that we will be faced with litigation a mere 8 times on average! That's around once every 5 years throughout our career!

The UK now has the second highest litigation against Dentists, overtaking America and only just being beaten by Iran! 

Recently, I attended a day of workshops run by Dental Protection in managing risk and minimising the likelihood of being sued. They run a series of 4 workshops which focus on:

Here is a brief summary of some of the ways to help minimise your risk of litigation. See another post about 'Why people complain.'

Difficult situations may arise from interactions of the following 3 factors:

1. Patients e.g. demanding, unrealistic expectations, anxiety, language barriers, financial situations, medical history etc.
2. Environmental e.g. time pressures, lack of or faulty equipment, NHS dentistry? 
3. The Dental team e.g. poor communication between members of the team, lack of skill, poor teamwork, personal problems

Choose an emotionally intelligent response!

1. Recognise and diagnose the difficulty of the situation - 'We're having difficulty agreeing on what course of treatment to take aren't we?'
2. Support the patient e.g. active listening and empathy, as well as using tension skills e.g. acknowledging the problem and stating your boundaries
3. AID model  

Acknowledge the patient's position

Inform them about your position

Discuss a way forward

Sometimes when you are unable to come to an immediate solution with a patient. In these cases:

• Ensure expectations are realistic
• Talk to trusted colleagues 
• Time a time out
• Identify, develop and use support systems e.g. Indemnity provider

Consent in dentistry is essential but can be a bit of a grey area. Consent is defined as:

 'permission for something to happen or agreement to do something'.

In order for consent to be valid, a patient must have:

1. Autonomy i.e. make the decision for themselves
2. Capacity i.e. understand and assimilate information in order to make a decision which they can communicate
3. Adequate information i.e. risks, benefits, costs of treatments as well as the consequences of doing nothing

I briefly mentioned this before in my EBD post, but coming to a decision and involving the patient in this process helps establish trust, you can also check patient understanding as well as learning about their values. 

70% of litigation is related to poor communication from the dentist and patients often prefer a collaborative role, so by using a shared decision making approach you can increase patient satisfaction and reduce the risk of litigation. 

A lot of patients ask this and it may seem that your shared decision making approach has failed but a lot of patients are overwhelmed with the treatment options you give them and so reiterating the choices or rephrasing the way you answer can facilitate their own choice for example:

'It sounds like you really don't like the idea of having a tooth taken out, so if I were you, with your values and feelings, I might choose to have a root canal treatment over an extraction.'

If they really don't state a preference and want to go with your recommendation, then always document this on their notes!

Sorry that the title of this post is rather pessimistic, I'm not usually one for propagating the negativity that is spreading through our profession like the plague, but figures don't lie and gone are the days where there was only a 1 in 3 chance of getting sued!

Minimising the risk of complaints is a vital skill we all need to acquire as well as learning how to handle complaints locally if they arise so things don't escalate any further!

Thanks to Dental Protection and Daniel Shaffer for running these educational workshops - I would highly recommend them to all dentists, but especially to Foundation Dentists like me!

Have you attended one of these workshops by Dental Protection? Please leave any comments or thoughts below! 

There are 3 levels of safeguarding in dentistry:

Level 1 - a basic understanding of safeguarding principles in practice

Level 2 - a more detailed understanding of safeguarding procedures who can observe and alert others to possible issues

Level 3 - a practitioner who holds the decision of what to do when issues arise. Involved in assessing, planning, intervening and evaluating the needs of people deemed at risk. Must be able to share information safely.

According to the Department of Health, 'Health services have a duty to safeguard all patients but provide additional measures for patients who are less able to protect themselves from harm or abuse.' 

Who may be 'at risk'?

Examples of vulnerable adults:

• Autistic patients
• Patients with down syndrome
• Dyslexic patients
• The elderly
• Patients who cannot communicate effectively e.g. language barriers, blind/deaf
• Dementia patients
• Patients with significant social histories e.g. lower social classes, alcholics, drug addicts, homeless people
• Patients with mental health issues

There are 2 principles in safeguarding: Prevention and Reactionary.

There are several procedures and policies you must abide by when employing and training staff to comply with safeguarding guidelines.

CQC requirements state there must be a person who is level 3 trained to be registered as a lead and all other professionals need be registered with a professional body. 

1. Sexual

2. Emotional

3. Physical

4. Neglect

Who should you go to if you have concerns?

For advice:

• Consultant paediatrician
• Child protection nurses
• Social services (informal discussions)
• Child's health visitor, school nurse or GMP

If you have serious concerns:

• Discuss with your defence organisation (as you should try to gain consent to refer to other services but this may not be appropriate e.g. if you think there may be serious risk of harm to a child)
• Refer for a medical examination
• Social services (phone and written communication)
• Police 
• Nominated safeguarding personnel in the area e.g. hospital safeguarding officer
• NSPCC

In summary it is important to be vigilant when dealing with vulnerable patient groups especially since now there is a lot of awareness of safeguarding with cases such as Baby P and Jimmy Saville fresh in our minds.

Sources:

Every Child Matter - Department of Health

Health and social care information centre

Safeguarding Act 2006

Children's Act 1989

Human Right's Act 1998

United Nation Convention on the Rights of a Child

Education Act 2002

Sexual Offences Act 2003

Children's Act 2004

Mental Capacity Act 2005

Child Protection and the Dental Team

General Dental Council: Guidance on Child Protection and Vulnerable Adults

The Department of Health: Safeguarding Adults