Mental Capacity Act: Using The Key Principles In Care Planning
The Mental Capacity Act has made a real difference to social workers in their practice, particularly the kind of key principles that are engendered in the act. It’s a very good piece of legislation, very visionary, and it’s actually based on really sound social work practice which is ensuring that the person is at the heart of all the decisions that are made with them or for them, that social workers really do use their skills to engage and listen to and understand what the needs and wishes of that person are, and that they balance, ensuring that the person is able to make the decisions and weigh out the consequences of the decisions and therefore be able to make what might be unwise decisions, but they have the capacity to do that against where they need assistance with those decisions being made for them but ensuring that those decisions continue to be in their best interests. So, the whole tenure of it really frames in legislation what is really good social work practice in person-centred, empowering work with people. The Mental Capacity Act will help to make sure people get their rights, as long as it’s done properly and with the person and the support that they need to do that. You know, because everybody has the right to live their life to the full and reach their full potential. That may take a little bit longer for someone with a learning disability than it might do for someone who doesn’t have a learning disability, but we all learn differently. I think the Mental Capacity Act has made a difference predominantly because what it’s done is provide a framework to help think through often complex clinical situations. Fundamentally, what the act has done is shifted the emphasis towards choice and encouraging autonomy and self-determination. It doesn’t mean to say that we don’t have responsibilities for people who might be seen as vulnerable and in some way at risk, but it clearly says the starting point here is to encourage choice and to respect people’s autonomy. But equally, it recognises that there is a need to be able to take decisions on behalf of people who may because of their learning disability or for many other possible reasons can’t make that decision for themselves, but you need to do it in a way that is the least restrictive as possible which still ensures as far as possible choice and participation and that of course is fundamentally done through the care-planning process and through the support that people have. My view is that anybody who’s involved in care planning needs to consider the five key principles in the Mental Capacity Act. That is, firstly, that we are all deemed to have capacity. So we start from the premise that we can all make decisions for ourselves, that we’re all autonomous individuals and have the right to be so and that there needs to be some evidence to displace that fact. Secondly, and one I think is very empowering about the act, is that we’re all entitled to make unwise decisions, and that just because we make an unwise decision doesn’t mean there should be a question about our capacity. Thirdly, is that each of us are entitled to every support being given to us to enable us to make our own decisions. So, it’s only after you’ve got through those first three principles that if you then come to the conclusion that an individual hasn’t got capacity to make a specific decision that you then move onto the fourth principle which is about in those circumstances you must make the decision in the best interests of the individual concerned. And lastly, is that whatever option you come up with must be the least restrictive on the individual. In order to make it a lasting care plan, one that actually achieves the right ambitions of the people, it needs to start, it needs to start with the person and what they want to do. If you don’t start there, you’re forever trying to play catch-up, and actually, it’s not resource efficient and it certainly doesn’t improve anybody’s quality of life. What I would like a care plan to do is to focus on the things that a person can do as much as possible. If you’re not unconscious, I think there are some decisions that you are going to be able to make. They might be fairly simple decisions, but they can be very important to the person themselves. So, it might be “Do I have the capacity to decide what to wear today out of a choice that is given me? Do I have the capacity to think that I’d like to sit in the sun or in the shade? Or to eat ice cream or broccoli?” I mean, all kinds of things, it’s enabling the person as much as you can. So, avoid the idea of global incapacity because these may seem like little decisions, but they can be very important to the person. Any care planning must respect and respond to the needs of the individual patient, and I think there’s a danger in these hurried and pressurized times that pro forma responses are put into place. Good care, good care and treatment for adults lacking capacity is personalized and individualistic. There’s this idea that people can’t do this and can’t do that, and there are blanket restrictions on when you can go to your bedroom and blanket restrictions on what time you get up and go to bed. These are people in their own home, they should be able to think, you know, “Would I fancy a bit of a duvet morning?” But of course, they’re often not allowed to. And we would all get a bit resentful, I think, and probably harder to care for if we’re not recognised as individuals. I might like to stop up late and watch something on TV. It would be immensely annoying to be packed off to bed for staff convenience at half-past six or half-past seven or in some cases, one hears of, half-past five. In any care plan prepared for the court of protection, details should always be given in particular of why the arrangements set down in a care plan are in that individual’s best interests. Especially when we are talking about care plans prepared in the contexts of deprivations of liberty, you must always be particularly clear about why the arrangements are the least restrictive option for the person concerned. The judge is always going to be concerned to know that there’s not something else that could be done which in some way, impinges less on the person’s liberty. A really good example of best practice is to have outlined in the care plan why the options that are not being pursued are not being pursued. And in the context of deprivation of liberty, you need to say in terms and explain in terms why it’s said that that really is the least restrictive option for the person concerned. One would hope that professionals seek to find as least restrictive a care plan as possible for any person they’re working with, and I think if they can honestly say they’ve done that and taken all the step towards that and clearly if a DoLS, a Deprivation of Liberty Safeguard, is called for, they must seek authorisation for that. And we know of examples, even very recently, of people who are held unlawfully or removed unlawfully from say their family circumstances. And it’s something we have to guard against, but of course, it’s why the courts are there too because at the end of the day, the Court of Protection will take a view on this. Under the Mental Capacity Act, capacity is seen as something that is decision, and also time, specific, and we can, we can imagine how it can be used to support people’s decision making when it comes to rather specific decisions like choices around how to spend your money, for example, or whether or not to accept a particular treatment. But I think it’s much broader than that. I do think it is about how do you support people in a way that enables them to have a full and active life as independent as possible but at the same time, managing issues, risk, and protecting people from harm. So, it is really about bringing those two aspects together and ensuring people have an active life in which they are free to do the things they enjoy and are safe to do that. I think what social workers really like about the act is it puts into a legislative framework really good, sound social work practice, really excellent person-centred approaches to working with individuals, and ensuring that that particular person’s needs, and feelings, and wishes are weighed up in terms of the decision making about how their current support is delivered. Another thing the Mental Capacity Act does, which I think is really important, is it says to people “Look, it may well be, we understand, that many of us as we age may lose the ability at certain points to make certain kinds of decisions.” One of the things the act does is it gives people certain kinds of legal tools to enable them to carry forward certain kinds of decisions that are very, very important to them at a time in the future when they may lose capacity. None of us know what’s going to happen tomorrow, you know, and maybe what needs to happen is where the people are, um, like in a, a care home, a residential home or their own home, um, maybe, um, it should be that it’s all discussed, and each person does an advanced decision so that you know that everything’s put into place for when it, if it does happen. So you’re seeing this piece of legislation coming out of some fundamental common law principles that are about protecting and promoting adult autonomy and carrying them forward to the point where an adult may lack capacity. It does something else as well, which is really important. It focuses, when an adult is assessed as lacking the capacity to make a certain kind of decision, it focuses on promoting and protecting their best interests. That’s all I think this really is, a really useful and principled piece of legislation. And, I think it’s absolutely vital that all health professionals that may be involved in the care and treatment of adults lacking capacity, and that’s a lot of health professionals, are familiar at least with its basic principles and its core, its core legal, um, tools and issues, so I think a very important piece of legislation.