Quality standard

Quality statement 1: Supported decision making

Quality statement 1: Supported decision making

Quality statement

People aged 16 and over who may lack capacity to make decisions are supported with decision making in a way that reflects their individual circumstances and meets their particular needs.

Rationale

People using health and social care services should be empowered to make decisions for themselves wherever possible. They may experience difficulty and need support with a range of decisions, including those about their care and treatment, financial matters and day-to-day living. Having the mental capacity to make decisions can change, depending on the person's circumstances and the type of decision that needs to be made.

To support people in a way that is appropriate to their circumstances and meets their needs, practitioners need to understand what is involved in a particular decision, and which aspect of decision making people may need support with and why. The support may include help with communication such as involving significant and trusted people (including family members, carers and independent advocates or specialist services) in line with the person's needs and wishes. It may also include identifying a location where the person feels more at ease or times of day when the person's understanding is better.

Quality measures

Structure

a) Evidence of local policy and guidance about which interventions, tools and approaches should be used to support decision making in people aged 16 and over who may lack capacity to make decisions.

Data source: Local data collection, for example evidence of providers implementing locally tools and approaches described in chapter 3 of the Mental Capacity Act Code of Practice.

b) Evidence of local arrangements to ensure that people aged 16 and over who may lack capacity to make decisions are supported to do so in a way that reflects their individual circumstances and meets their particular needs.

Data source: Local data collection, for example evidence of significant and trusted people, advocacy service or specialists such as occupational therapists, psychologists, or speech and language therapists being involved in supporting the decision-making process.

Process

Principles of supported decision making should be applied to all decisions made by people who may lack capacity. However, the recording of the decision-making process should be proportionate to the decision being made. For measurement purposes, commissioners may wish to focus on decisions that have significant consequences.

a) Proportion of decisions made by people aged 16 and over who may lack capacity where the decision-making process reflected their communication needs.

Numerator – the number in the denominator where the decision-making process reflected the person's communication needs.

Denominator – the number of decisions made by people aged 16 and over who may lack capacity.

Data source: Local data collection, for example local audit of patient records or care plans.

b) Proportion of decisions made by people aged 16 and over who may lack capacity where the decision-making process involved the person's significant and trusted people.

Numerator – the number in the denominator where the decision-making process involved the person's significant and trusted people.

Denominator – the number of decisions made by people aged 16 years and over who may lack capacity.

Data source: Local data collection, for example local audit of patient/client records or care plans.

c) Proportion of decisions made by people aged 16 and over who may lack capacity and had no significant or trusted people, that involved an advocate.

Numerator – the number in the denominator that involved an advocate.

Denominator – the number of decisions made by people aged 16 and over who may lack capacity and had no significant or trusted people.

Data source: Local data collection, for example local audit of patient/client records or care plans.

Outcome

a) Proportion of people who may lack capacity who feel supported to make their own decisions.

Numerator – the number in the denominator who feel supported to make their own decisions.

Denominator – the number of people who may lack capacity.

Data source: Local data collection, for example surveys of people's experience of supported decision making in health and social care, feedback gathered by voluntary sector organisations supporting people who may lack capacity, and their families and carers.

b) Proportion of carers of people who may lack capacity who think that the person they care for is supported well to make their own decisions.

Numerator – the number in the denominator who think that the person they care for is supported well to make their own decisions.

Denominator – the number of carers of people who may lack capacity.

Data source: Local data collection, for example surveys of family members and carers on their experiences of supported decision making in health and social care, feedback gathered by voluntary sector organisations supporting people who may lack capacity, and their families and carers.

What the quality statement means for different audiences

Service providers (such as community services, local authorities, private care providers, general practices and hospitals) ensure that appropriate support with decision making forms part of care planning processes for people receiving health or social care services. They develop local policy and guidance about which interventions, tools and approaches should be used and ensure that practitioners undergo training to help them apply the Mental Capacity Act 2005 and its Code of Practice. They ensure that training is available and tailored to the role and responsibilities of the practitioners and the specific needs of the individuals. They also ensure that the training covers new staff and pre-registration, and the continuing development and practice supervision for existing staff.

Health and social care practitioners (such as social workers, care staff, GPs, doctors, nurses and therapists) take a personalised approach to supporting people who may lack capacity. This includes making any reasonable adjustments and considering the wide range of factors that can affect a person's ability to make a decision. They support effective communication by allowing sufficient time for discussions and by using a range of tools such as inclusive communication, visual materials, visual aids, communication aids and hearing aids. These help people to take an active part in decision making. Health and social care practitioners also include family members, carers, and significant and trusted people in supporting decision making, in line with the person's needs and preferences, and involve an advocate when needed.

Commissioners (such as local authorities, clinical commissioning groups and NHS England) commission services that require practitioners to apply the Mental Capacity Act 2005 and its Code of Practice. Specifically, they commission services that have arrangements for competency-based training and assessment of relevant communication skills, as well as sufficient capacity within advocacy services available to people in need of support.

People aged 16 and over who may need help with making decisions are given support that is tailored to their own needs and circumstances. This might include help with communication or understanding information and what the different choices might mean for them, or allowing them sufficient time to consider the options. They may be given information in a range of media including 'easy read' or visual format. They may also have help from their family members, carers or advocates when they need to make a decision.

Source guidance

Decision-making and mental capacity. NICE guideline NG108 (2018), recommendations 1.2.4 and 1.2.11

Definitions of terms used in this quality statement

People who may lack capacity

People who are experiencing difficulties making decisions due to health conditions or particular circumstances they are in at the time a specific decision needs to be made. These include decisions about their care and treatment, financial matters and day-to-day living. Examples of health conditions or particular circumstances include, but are not limited to, those with:

  • dementia

  • a severe learning disability

  • a brain injury

  • a mental health problem

  • a stroke

  • unconsciousness caused by an anaesthetic or sudden accident.

[Adapted from Mental Capacity Act Code of Practice and expert opinion]

Individual circumstances and particular needs

This should include understanding and taking account of:

  • the person's physical and mental health condition

  • the person's communication needs

  • the person's previous experience (or lack of experience) in making decisions

  • the involvement of others and being aware of the possibility that the person may be subject to undue influence, duress or coercion regarding the decision

  • situational, social and relational factors

  • cultural, ethnic and religious factors

  • cognitive (including the person's awareness of their ability to make decisions), emotional and behavioural factors, or those related to symptoms

  • the effects of prescribed drugs or other substances.

This knowledge should be used to develop a shared and personalised understanding of the factors that may help or hinder a person's decision making, which can be used to identify ways in which the person's decision making can be supported. It should also be recorded in the person's written care plan. [NICE's guideline on decision-making and mental capacity, recommendation 1.2.4]

Independent advocacy

Independent advocates can have a role in promoting social inclusion, equality and social justice and can provide a safeguard against the abuse of vulnerable people. Independent advocates help people say what they want, help them secure their rights, represent their interests and help them obtain the services they need. Together with their provider organisations they work in partnership with the people they support, helping the person to speak out for themselves or speaking out on their behalf.

Independent advocates most likely to be involved in decision-making are Independent Mental Capacity Advocates (IMCAs), Independent Mental Health Advocates (IMHAs) and Care Act Advocates. [Adapted from NICE's guideline on decision-making and mental capacity, terms used in this guideline]