Home sweet home – domiciliary care for vulnerable dental patients
Debbie Ganguli answers some questions about providing appropriate, effective care for vulnerable patients in a domiciliary setting.
As healthcare professionals, I am quite sure that our patients’ safety and wellbeing is constantly paramount.
Recently, the whole concept of safeguarding the public has made its way further up the political agenda. Especially after such high-profile scandals as Shipman, Stafford and Baby P.
However, a rise up the political agenda can often lead to decisions taken in haste. Seldom do quick decisions lead to good governance.
Domiciliary care is something that many practices get involved in. It often puts those providing it in contact with vulnerable patients. But it comes with its own challenges that are sometimes quite different from working in a practice setting. Challenges which are important to meet, especially in light of the political attention on these issues.
It’s perhaps worth quickly reminding ourselves what we mean when we talk about ‘safeguarding vulnerable patients’ in a professional capacity.
The Care Quality Commission (CQC) has made the safeguarding of vulnerable patients one of its underpinning priorities. In July 2015, it published a Statement on CQC’s roles and responsibilities for safeguarding children and adults (essential reading, available at all good bookshops!). It quotes as its vision:
‘Safeguarding is a key priority for CQC and people who use services are at the heart of what we do. Our work to help safeguard children and adults reflects our focus on human rights. Also, the requirement within the Health and Social Care Act 2008 to have regard to the need to protect and promote the rights of people who use health and social care services.
‘Regulated providers of health and adult social care services all have a key role in safeguarding children and adults in their care who may be at risk of abuse and neglect. We monitor how well providers are doing this by assessing the quality and safety of care they provide. This is based on the things that people tell us matter to them.
‘There are significant differences in the laws and policies that shape how we safeguard children and how we safeguard adults. The legal framework to protect children is contained in Working together to safeguard children (2015).
‘For adults, the Care Act 2014 gave safeguarding adults a legal framework for the first time. However, the overarching objective for both is to enable children and adults to live a life free from abuse. This cannot be achieved by any single agency. Every organisation and person who comes into contact with a child or adult has a responsibility and a role to play to help keep children and adults safe.’
I think the CQC is suggesting (in pleasant language) that this is a problem it wants to pass onto all of us as it cannot be their responsibility alone. So, what should we be doing? What should we consider? How do we apply this reasoning to domiciliary care?
There is a massive funding gap in domiciliary care. It has been under governments of all colours for as long as I can remember – it was ever thus.
As a practice owner, my team and I continue to provide domiciliary care where required. This is something that many practitioners shy away from. This is likely due to constraints in providing a full service alongside the duties in the surgery. There are a number of issues that raise their head when it comes to domiciliary care:
- There is a lack of training in how to provide effective care due to the massive funding gap
- The vulnerable will often become even more vulnerable in their own homes. In the surgery, you have the latest technology close to hand, clean surfaces, known electricity supply. This all changes out of the surgery setting and in a vulnerable person’s home; limiting the type of dentistry that you can offer before you have even started
- You become more vulnerable – even working in pairs, you open yourself up in a medicolegal sense. You are working in an unfamiliar environment, someone else’s territory
- What the son and the daughter or the mother and father of the vulnerable person in question want, is not always what is needed. This requires careful handling.
Delivering effective care
If you are in the situation where you have to provide domiciliary care or would like to provide domiciliary care, there are a few things to bear in mind.
Ensure everyone in the practice is training to ask the questions you need the answers to. A thorough initial phone triage, for example, will give you an excellent insight into the requirements of the patient in need of domiciliary care. It will highlight what level of care can be provided.
Domiciliary visits aren’t quick. Ensure that you allow enough time for the initial consultation – you don’t want to be rushed because you have to get back to the surgery for the next patient.
Book sensibly by seeing your domiciliary patient last thing in the day, or as the last patient of the morning. Domiciliary patients are often not good for visits in the morning, as this is when carers are more likely to be in, readying them for the day.
Manage the expectations of everyone
Ensure there is a carer or family member present, and ask for care plans, doctor’s notes and up-to-date medication.
Do not be scared to liaise with other healthcare professionals before embarking on treatment. Care managed across both medical and dental teams works in favour of the patient. Be prepared to have a cup of tea and a biscuit – you may be the only visitor your patient has had in a long time (other than their carer)!
Manage the expectations of everyone – and this means loved ones and carers too. Just because they think that their 90-year-old-grandmother needs dentures doesn’t mean it is the right thing for the patient, even if they do have power of attorney.
Do not forget that the patient needs to be the one to consent to treatment. Where they are not able to consent, remember your duty of care, and take the time to discuss treatment with peers and other healthcare professionals – and endeavour to provide treatment with your patient in mind.
Sadly, funding for the provision of domiciliary care on the NHS is not as readily available as even it once was. This makes it harder for practices to offer visits.
The former community dental services have tight budgets when it comes to domiciliary care and while they try to offer a good service, the waiting times for these patients can be long as the dentists in these services are also offering other services.
It is a challenging service to provide, given all the factors to consider from both a financial and logistics perspective. Often these days, nursing homes and carers may approach private practices for domiciliary care.
In these circumstances don’t forget to account for your time when providing treatment costs: factor in travel costs, time out of surgery, number of appointments (these may be greater than normal depending on the patient’s health requirements) – give the patient and carers a clear treatment plan with clear costs, including travel.
It is always better to overestimate and then give the patient a pleasant surprise with a lower cost at the end.
Remember the most successful domiciliary visits are those that you planned well.
If you are going to do lots of visits, invest in a care box. Keep it stocked with consumables and basics at all times and add materials as needed. This box should be on wheels to make it easier to transport (and keeping moving and handling in mind). Have a dirty box for instruments, don’t forget yellow sacks (never leave any waste behind), take hand gel (and use it).
If you are thinking of providing a domiciliary service – to a number of care homes, for example – perhaps invest in a portable handpiece and make sure it is charged.
My best tip is maybe the most practical one – be prepared to kneel on the floor for much of the visit, and take something to kneel on for comfort and infection control.
Domiciliary visits are tiring. Take water to drink and a snack for the road, and go armed with a sense of humour and a warm smile!
An ageing population is going to lead to a greater demand on these types of services in the years to come. Medical domiciliary care is free at the point of service. Some nursing homes make provision for dental care in their fees and some do not.
Perhaps some kind of joined up thinking across health and social care is what’s called for?
Domiciliary care: top tips
- Triage is crucial
- Allow enough time
- Manage expectations about treatment
- Be clear about the costs
- Plan ahead.
Disclaimer: The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of any agency of the NHS, Department of Health or other public body.
This article first appeared in Oral Health magazine.