Making decisions in dementia care: has the Mental Capacity Act helped social work practice in England and Wales?

Latest research findings

Care and support of people with dementia and their carers already form substantial parts of many social workers’ caseloads. This overview reports recent findings from studies of social work practice in England and Wales focusing on the Mental Capacity Act 2005. Details of the Act are contained in the highly regarded and accessible Code of Practice (Ministry of Justice, 2007).

This overview focuses on two themes:

• What changes has the new legislation made to social work practice and how are these viewed by social workers?
• What has been the impact of the new legislation on social work relationships with other professionals?

A recently published overview of the MCA (Jenkins, 2012) would be a good primer for anyone seeking information. Its publisher, the Mental Health Foundation (MHF), supported the development of the Act and has helped to develop many resources to support practice with adults of all age groups and with many reasons behind the loss or absence of decision-making capacity.

Such resources are easily accessible on the Social Care Institute of Excellence website. One recent study in which the MHF was involved was a detailed overview of the workings of best interests’ principles and the ways in which these operate in practice around the making of best interests’ assessments and decisions (Williams et al, 2012).

This report helps answer the first of our questions: the MCA did indeed change social work practice, and most of this has largely been welcomed. Social workers and other practitioners report that deciding if a person has capacity to make a specific decision is difficult, but perhaps this is why they are involved in this. After all, social workers would surely be the last to say that having a condition such as learning disability or diagnosis of dementia would be sufficient to take away people’s rights to make a decision.

Lack of capacity

The research also found that social workers often disputed or challenged the record of an individual’s lack of capacity if they felt the assessment had not been decision-specific; this was often seen as validating the social work role to advocate for individuals (Williams et al, 2012, p132).

Likewise, this report notes the need for decisions to be made in the real world, which so often involves some degree of compromise, for instance, in cases where a carer’s needs have to be considered alongside the best interests of a person lacking capacity: “Best interests decisions often had to balance the needs of one person against another.” (Williams et al, 2012, p11).

A second research study helps answer the second question: What has been the impact of the new legislation on social work relationships with other professionals?

The EVIDEM research was a multi-method study which explored the implementation of the MCA 2005 by drawing on face-to-face interviews with older people and practitioners from social and health care services. Data revealed strong support for many aspects of the MCA, with social workers pointing to its welcome clarity, acceptable value base, and supportive presumption of capacity unless proven otherwise as being positive elements of the law.

Many were able to contrast this to the practice situations before the Act, where there was more confusion, a dominance of medical decision-making, and limited opportunities for people to make plans in advance with any confidence that they would be adhered to. Safeguarding practice (for example, the prevention of elder abuse) is perceived to be easier under the new decision-making framework (Manthorpe et al, 2009). Interviews with safeguarding leads over the course of this study generated a developing picture of growing confidence amongst this group.

Joint working

The EVIDEM study also found that not all social care practitioners are well informed about the Act and their responsibilities. Social workers could be a welcome source of advice for them. Safeguarding practitioners also reported being more often contacted with queries than previously, enabling them to build up a sound reputation as knowing what is lawful, particularly as many of them later took on responsibilities for implementing the Deprivation of Liberty Safeguards (DoLS) amendment to the MCA.

Not everything was positive, of course, and the Alzheimer’s Society report that was linked with the EVIDEM study (Alzheimer’s Society 2012) detected growing interest in how to prevent and respond to financial abuse, especially when people with dementia have fluctuating capacity or appear to be able to make unwise decisions.

Social workers’ relationships with other professionals concerning the MCA also cover advance planning and advice. In health care, advance planning is often associated with end-of-life care and decisions about preferred place of death and treatment (Seymour et al, 2010). For social workers, advance planning may mean talking with service users and carers about decisions and plans early on; for example, about moving house or making arrangements about bills and care services.

Some third-sector or voluntary sector groups can be expert in providing such support, but others may have sketchy ideas about the legalities (Manthorpe et al, 2012). Social workers and other professionals need to know which local support services offer advice and information and the extent of this, given that older people are likely to turn to community sources of support (Samsi and Manthorpe, 2011).

The impact on practice
Three potential implications for social work practice could be drawn from these studies.

1. After the flurry of training around the MCA and Deprivation of Liberty Safeguards, refresher training and skills’ audits might be needed by teams. Auditing of case notes could prompt action to see if practitioners are abiding by the MCA; for example, if the two-stage test of capacity is being carried out, or if there is evidence that people have been advised about plans and making arrangements for possible loss of capacity.
2. Establishing capacity may feel highly problematic to some social workers and this should be discussed in supervision or peer-support opportunities. Not all cases will be clearcut and there will often be complex interpretations about people’s ability to make their own decisions.
3. Safeguarding staff will probably not find that demand for their advice and guidance decreases. There is still high turnover of staff in many social care settings and care managers do not have professional qualifications in many instances.

Questions for social work practice could include:

• Are we using the MCA sufficiently as a prompt for discussion, case review and audit in teams and services?
• Where locally are the best sources of support with MCA matters for people with dementia and carers? What is the evidence that this is what people need? Do we ask service users and carers for feedback on referrals?
• Do we make the most of independent Best Interests Assessors as ‘eyes and ears’ inside services from a commissioning and quality assurance point of view?

References and further reading

Alzheimer’s Society (2012), Short Changed – Protecting people with dementia from financial abuse, London: Alzheimer’s Society

EVIDEM: Evidence-based Interventions in Dementia: Mental Capacity Act

JenkinsK. (2012),‘Mental Capacity and the Mental Capacity Act 2005: a literature review‘, London: Mental Health Foundation,

Manthorpe, J., Rapaport, J., Harris, J., and Samsi, K. (2009), ‘Realising the safeguarding potential of the Mental Capacity Act 2005: Early reports from adult safeguarding staff‘, The Journal of Adult Protection, 11: 2, p13-24

Manthorpe, J., Samsi, K., and Rapaport, J. (2012), ‘More of a leg to stand on’: Views and usage of the Mental Capacity Act 2005 among local Alzheimer’s Society and carer organisations: Findings from the EviDEM MCA project‘, Aging and Mental Health, 16:1, p102-109

Ministry of Justice (2007), ‘Mental Capacity Act 2005: Code of Practice’, London: The Stationery Office

Samsi, K., and Manthorpe, J. (2011), ‘I live for today’: A qualitative study investigating older people’s attitudes to advance planning’, Health and Social Care in the Community, 19:1, p52-59

SCIE Mental Capacity Act resource

Seymour, J., Almack, K., and Kennedy, S. (2010), ‘Implementing advance care planning: a qualitative study of community nurses’ views and experiences’, BMC Palliative Care, 9:4

Williams, V., Boyle, G., Jepson, M., Swift, P., Williamson, T. and Heslop, P. (2012), Making Best Interests Decisions: People and Processes, London: Mental Health Foundation

Acknowledgements and Disclaimer: This overview draws on independent research commissioned by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research scheme (RP-PG-0606-1005). The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health.