I read with some interest an article by Debbie Ganguli domiciliary care dentist describing the challenges faced by dentists when providing a dentistry service to vulnerable people in their own homes.
Given the problems experienced by many in trying to obtain an appointment at a dentist, I was somewhat surprised to learn that there are some practitioners who provide this service. As a practice owner, Debbie and her team 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:
1. There is a lack of training in how to provide effective care due to the massive funding gap. 2. 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. 3. 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. 4. 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
Debbie says that 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.
Managing the expectations of everyone
When visiting the domiciliary patient ensure there is a carer or family member present, and ask for care plans, doctor’s notes and up-to-date medication.
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.
Remember the most successful domiciliary visits are those planned well.
Domiciliary care for vulnerable dental patients, does not attract the attention it deserves. There is surely a great demand for these services which cannot be met by funding alone. The commitment of Debbie Ganguli and her team is worthy of recognition, and hopefully encourages others to provide domiciliary care dental services. 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 we may see in future joined up thinking across health and social care may help to meet the demand.
Albert Cook BA, MA & Fellow Charted Quality Institute Managing Director Bettal Quality Consultancy