The Best Interests Case Conference

1. The Purpose of a Best Interests Case Conference

The Best Interests case conference

The Best Interests case conference (also known as the Best Interests meeting) is a formal meeting (or series of meetings) that involves;

  1. The Decision Maker (whose role it is to co-ordinate and chair the meeting);
  2. All persons being consulted; or
  3. Some of the person’s being consulted (with the views of those not present being shared by the Decision Maker); and
  4. The person lacking capacity; or
  5. The representative of the person lacking capacity. 

The purpose of a Best Interests case conference

The purpose of the Best Interests case conference is to;

  1. Hear the views of everyone present;
  2. Share the views of those persons consulted but not present;
  3. Provide relevant information about the available options;
  4. Share ideas about possible options;
  5. Weigh up the benefits and risks of all the available options;
  6. Provide opportunities to challenge and question;
  7. Support the Decision Maker to make a decision;
  8. Support those person’s present to understand how the decision has been made; and
  9. When the decision is made, agree how best to implement it in the least restrictive way.

2. The Best Interests Case Conference and Everyday Decisions

On the first occasion that a decision about routine care or treatment needs to be made it may be useful to arrange a Best Interests case conference, although there is no requirement to do so under the Act.

A Best Interests case conference may be particularly useful if;

  1. The decision is major;
  2. A number of people are involved; or
  3. The likely impact on the person is significant.

Acts can then be carried out routinely to implement the original decision each time that the care or treatment is required, so long as the manner in which acts should be carried out is;

  1. Agreed through applying the Best Interests principle; and
  2. Clearly set out in the person’s Care and Support Plan, Care Plan or Support Plan.

3. Deciding whether to Arrange a Best Interests Case Conference

There is no requirement under the Mental Capacity Act to arrange a Best Interests case conference during any Best Interests decision making process. As Decision Maker it is your responsibility to decide whether to arrange a Best Interests case conference or not.

Whether or not you arrange a Best Interests case conference will depend on a range of factors including;

  1. The specific circumstances and needs of the person;
  2. The decision that is to be made; and
  3. The urgency of the decision to be made

Arranging a Best Interests case conference can be particularly helpful when;

  1. The decision is complex or likely to have serious consequences for the person; and
  2. There is time to arrange a meeting; and
  3. A significant number of people with a range of views are consulted; or
  4. There is likely to be some conflict or challenge about what is in the person’s Best Interests.

Some of the factors that you should consider include;

  1. The gravity of the decision to be made;
  2. The timeframe in which a decision must be made;
  3. The number of people to be consulted;
  4. The availability of the person’s consulted to attend a meeting;
  5. The number of options to be explored;
  6. Whether there is likely to disagreement or challenge;
  7. Whether the decision is likely to be contested.
If you are not sure whether to arrange a Best Interest case conference you should seek the advice of your line manager.

4. Deciding who should Attend

As Decision Maker it is your responsibility to decide who should attend any Best Interests case conference that you arrange.

It is not paramount that every person consulted attends the meeting, and you should consider carefully the benefit of different people being there or not.

Some of the things you should consider are whether a particular person;

  1. Has relevant information about options, or about the incapacitated person’s views, beliefs and values;
  2. Is able to provide an expert opinion about the impact of available options on the person’s physical or mental health;
  3. Is able to provide you with the information through a report, or other means instead;
  4. Is available to attend the meeting;
  5. Is required to be present in order for the decision to be made;
  6. Will have an active role in implementing any decision that is made;
  7. Will they themselves potentially be affected by the decision that is made;
  8. Will facilitate or restrict the involvement of the person with their presence.

Where they exist the following people should always be invited to attend the meeting, and where possible steps should be taken to arrange the meeting, and where possible steps should be taken to arrange the meeting at a convenient time to facilitate their involvement;

  1. The person lacking capacity;
  2. An IMCA;
  3. The person’s representative.

The nature of attendance

When deciding the nature of a person’s attendance you need to decide whether they should;

  1. Attend all of the meeting;
  2. Attend the meeting long enough to provide their views and answer any questions;
  3. Attend the meeting in person;
  4. Attend via telephone, video link or other means.

The support of others

If you anticipate the meeting to be challenging it is also appropriate to discuss whether it would be beneficial for a manager, or a legal representative to attend. For example;

  1. If there is likely to be significant conflict between parties attending;
  2. If the decision to be made has legal implications for your organisation

You should also consider the need for a minute taker to be present for the purpose of recording what is said, considered and agreed at the meeting. This may be particularly useful when;

  1. There are a lot of people attending the meeting;
  2. There are a lot of options to explore; or
  3. The discussion is likely to be complex.

5. Facilitating the Involvement of the Person

The purpose of involving the person is to understand, as far as is reasonably ascertainable;

  1. What their views are on any matters affecting the decision;
  2. What is important to them; and
  3. What their preferred outcome may be.

The nature of the person’s involvement will depend on their ability to;

  1. Communicate their views on any matters affecting the decision; and
  2. Communicate what their preferred outcome may be; and
  3. Their wish or willingness to be involved.

As Decision Maker it is your responsibility to decide how to involve the person in the Best Interests case conference. When doing so you must have regard for the Code of Practice, which states that you must do whatever is possible to;

  1. Encourage the person to be involved in the decision that is to be made; and
  2. Permit the person to be involved in the decision that is to be made.

You must not make a decision about involving the person in the meeting based solely on;

  1. Their age;
  2. Their appearance;
  3. Their behaviour; or
  4. The presence of a particular physical or mental health condition.

Some of the steps that you should consider taking to facilitate the person’s involvement are;

  1. Arranging a venue that they will feel at ease in (for example their home environment or a day centre);
  2. Arranging a venue that meets their physical needs (for example a wheelchair accessible building);
  3. Setting a sufficient timeframe to allow them to share their views and digest information provided by others;
  4. Limiting the number of other people in attendance;
  5. Supporting the person to be involved through a range of means, including in person, through the telephone, video conferencing etc;
  6. Limiting the attendance of any consulted persons who are likely to hinder the involvement of the person;
  7. Preparing a meeting structure that is as simplified as possible;
  8. Establishing and providing any support or representation the person may need during the meeting.

In any record of the meeting you should document the steps that you have taken to involve the person in the Best Interests case conference and, if you decide not to involve them you must;

  1. Take steps to consult the person and gather their views to share at the conference;
  2. Ensure that they are represented at the meeting by a suitable person or an advocate; and
  3. Provide clear written evidence of your reasoning.

6. Arranging the Best Interests Case Conference

You should proceed to arrange the Best Interests case conference when;

  1. You have decided that a formal meeting is the best way of making a decision;
  2. You have decided who should be invited; and
  3. You have considered the steps that can be taken to involve the person who lacks capacity.

Some things to consider when arranging the meeting include;

  1. The availability of the venue in regards to the urgency of the decision;
  2. The location of the venue;
  3. The size of the meeting room;
  4. The facilities available at the venue, particularly in relation to accessibility;
  5. The duration of the meeting;
  6. Whether refreshments are available, particularly if the meeting is likely to be long;
  7. The availability of those person’s to be invited, particularly the incapacitated person and any IMCA or representative.

7. Preparing for the Best Interests Case Conference

Setting the Agenda

You should consider preparing a formal agenda to;

  1. Effectively manage the structure and timing of the meeting; and
  2. Ensure that the Best Interest principle is applied throughout the meeting.

Wherever possible, any agenda that you prepare should be shared with anyone who will be attending the Best Interests case conference before the day of the meeting.

Click here to access a tri.x agenda tool that can be used to structure a Best Interest Case Conference.

Consultation with others

Consulting with people who will not be attending

It is important that you consult before the day of the meeting with;

  1. Anyone who you have decided it is relevant to consult with; where
  2. You have decided it is not appropriate for them to attend the Best Interests case conference; or
  3. They are not able to attend the Best Interest case conference.

You need to gather;

  1. Any information that the person may have about the past and present wishes, feelings, beliefs and values of the person who lacks capacity; and
  2. Ascertain any views that the person has about what may be in the person’s best interests (and the reason for those views).

You must take steps during consultation to ensure that;

  1. The privacy of the person is protected; and
  2. Information that is not relevant to the decision to be made is not shared; and
  3. Information that the incapacitated person has requested remain private is not shared.

Any information gathered should be shared at the Best Interests case conference and considered in the process of making the Best Interests decision.

Consulting with people who will be attending

To assist you in effectively chairing the Best Interests case conference meeting it may be necessary to consult with those people who will be attending beforehand to obtain initial information about;

  1. Available options;
  2. Other options that may be available;
  3. The person’s initial views;
  4. Potential conflicts and challenges that may arise.

Providing information to prepare others

Providing information to prepare the person

If the person who lacks capacity is going to attend the Best Interests case conference you should provide them with the following information;

  1. The purpose of the meeting;
  2. Your role in the meeting;
  3. Their role in the meeting;
  4. The information that they will be asked to provide;
  5. Who else will be present;
  6. The information that others will be asked to provide;
  7. The agenda (where available);
  8. What is likely to happen after the meeting.

Wherever possible, the information should be provided to the person in a way that;

  1. Is most accessible to them;
  2. Allows time for them to process it; and
  3. You should consider any support that the person may need to understand the information provided.

You should also;

  1. Ask the person if they have any questions; and
  2. Establish whether the person is happy to represent themselves at the meeting; or
  3. Whether they require support or representation during the meeting.

Providing information to prepare others

You should provide the following information to everybody who is going to be present at the Best Interests case conference;

  1. The purpose of the meeting;
  2. Your role in the meeting;
  3. Their role in the meeting;
  4. The information that they will be asked to provide; and
  5. The agenda (where available).

Final checks before the meeting

It is always worth completing final checks to make sure that you are as prepared as possible for the meeting in order to prevent the need to delay the decision further.

You should make sure that you;

  1. Know who is going to be attending and who is not; and have
  2. Consulted everyone who is not going to be at the meeting (including, where relevant the person who lacks capacity);
  3. Provided information to prepare everyone who will be attending;
  4. Arranged any support or representation that the person requires; 
  5. Gathered all the information that you need about the available options;
  6. Prepared a means to effectively explore the benefits and risks of options;
  7. Decided how best to structure the meeting (either with or without the use of an agenda);
  8. Considered the need to schedule a break or arrange refreshments (if the meeting is lengthy or to facilitate the involvement of the person);
  9. Considered and arranged any support from a manager or minute taker; and
  10. Prepared copies of the agenda (if being used) for circulation at the meeting.

8. Chairing the Meeting

Co-ordinating the meeting

As Chair it is important that you make sure;

  1. The meeting starts and ends in a timely way;
  2. Everyone present knows the purpose of the meeting; and
  3. The meeting covers everything that needs to be covered; and
  4. The Best Interest principle is applied.

You should consider preparing a formal agenda to support the structure and flow of the meeting.

Click here to access a tri.x agenda tool that can be used to structure and Chair a Best Interest Case Conference.

The following guidance for co-ordination, structure and content of a Best Interests case conference is based around the steps set out in the agenda tool.

Step Guidance for Chair
Introduction

Introduce yourself and your role.

If the person lacking capacity is present allow them to introduce themselves, either directly or through their representative (which could be you).

Allow everyone in the room to introduce themselves, including their role and their relationship/professional involvement with the person.

Provide information about the role and involvement of those persons not present, and how they are to be represented.

Summarise the purpose of the meeting.

Clarify the nature of the decision that is to be made and the reasons for it (this should be clearly recorded on any Mental Capacity assessment).

Affirm that a Mental Capacity assessment has been completed, when and the outcome. Establish that the outcome is not contested.

Consider whether the person is likely to regain capacity and whether the decision can be delayed.

Affirm your role as Decision Maker and confirm that there is no Deputy, Donee of a Lasting Power of Attorney or other person more suitable to make the decision; or in the case of decisions about life sustaining treatment only there is no Advance Decision to Refuse Treatment.

If the decision can be delayed, if there is a Deputy or Donee that may be authorised to make the decision, or (in the case of life sustaining treatment) there may be an ADRT you should consider delaying the meeting, or seeking advice about continuing to act as Decision Maker.

The Person

Explain the need to keep the views, wishes, beliefs, values and rights of the person central to the decision that is made.

If the person who lacks capacity is present invite them to provide relevant information about their situation, what is important to them now and in the future, their views, wishes, beliefs and values (past and present) and their preferred outcome. The person can do this directly or can request a representative speak on their behalf;

Or

If the person is not present provide (or ask their representative to provide) the same information. You (or the representative) should be clear how this information has been gathered.

Available Options

Provide a summary of each available option, either verbally or in written form.

Invite persons present to provide further options and agree their viability. If they are viable you should include them with other options and consider them equally.

If there are a large number of options you should try to provide these to people before the meeting.

Risks and Benefits

Explore the risks and benefits of each available option in turn, setting out;

  1. The risks to the person;
  2. The benefits to the person;
  3. The likely impact of the risk or benefit on the person.

Click here for guidance about using a balance sheet approach to explore options.

Make sure that you allow everyone present to provide any views and information that they have. In particular you must make sure that you seek the views of the person (if they are present) and any IMCA (if present).

Conversations about risks should be evidence based, and not based on perceived risks associated with general anxiety and assumptions.

Views of those Consulted

If the person who lacks capacity is present you should seek their views about the preferred outcome.

If an IMCA is present you must seek their views about which outcome would be in the person’s Best Interests, and the reasons for their view.

You must then seek the views of all other person present about what may be in the person’s Best Interests and the reasons for it.

If you have information from people who were not able to attend the meeting, but who you have consulted beforehand this must also be shared.

Further Action

Identify any need to consult further or gather any more information before a decision can be made.

If so, you need to consider whether the decision can be delayed in order to gather the required information.

The Decision

Click here to access guidance about when a decision should be made at a Best Interest case conference.

If the decision can be made follow the guidance about how to make the decision by clicking here.

Implementing the Decision

If the decision is made, you should seek the views of person’s present about the best way to implement the decision, which must be done in a way that is least restrictive of the person’s rights.

Click here to access guidance about how to implement Best Interest decisions.

Reviewing the Decision

If the decision is made, you should seek the views of the person’s present about the best way to review the impact of the decision on the person.

Click here to access guidance about reviewing Best Interests decisions.

Managing disagreement

It is not unusual for there to be some disagreement during the Best Interests case conference about what is in the person’s Best Interests.

As Decision Maker and Chair of the meeting, it is your role to manage any disagreement and limit the negative impact of any conflict that occurs, particularly if the person who lacks capacity is present and likely to be affected by it.

A proactive approach

You should be clear about the following from the start of the meeting, and whenever conflict is likely;

  1. That the purpose of the meeting is to share views;
  2. That it is expected some views may be different;
  3. That it is important that everyone’s views are heard;
  4. That no one view is more important than another; and
  5. That everyone’s views will be considered equally during the decision making process.

If you anticipate conflict before the meeting begins you should seek the support of your line manager and;

  1. Agree a strategy to manage any conflict that may occur; or
  2. Consider the need for your line manager to support you during the meeting.

A reactive approach

If conflict occurs you should consider whether any of the following strategies may be helpful in managing any tension, seeking the support or your line manager as required;

  1. Explain the impact that the conflict is having on the meeting and other person’s present;
  2. A short comfort break to alleviate tension;
  3. Pause the meeting to talk privately with any particular persons who may be the cause of the conflict;
  4. Politely request that an individual withdraw from the meeting and make arrangements to consult with them separately;
  5. Delaying or rescheduling the meeting, if the decision can be delayed.

If the person that lacks capacity is present at the meeting you must remember that you have a requirement to do whatever is possible to;

  1. Encourage them to be involved in the decision that is to be made; and
  2. Permit them to be involved in the decision that is to be made.

If the presence or behaviour of anyone else present at the meeting is inhibiting the person’s involvement you must;

  1. Take appropriate action to address the behaviour; or
  2. Request the person withdraws from the meeting; and
  3. Make separate arrangements to consult with them.

Recording the meeting

You must record (or arrange for a minute taker to record) the following information, all of which should be used to support the decision to be made;

  1. Who was present at the meeting;
  2. Who was consulted outside of the meeting;
  3. The Decision to be made;
  4. The available options that were explored;
  5. The benefits and risks of each option;
  6. The past and present views and wishes, belief and preferences of the person, and how these were ascertained;
  7. The person’s preferred outcome; and
  8. The views of all people present and the reasons for those views.

If a decision is made at the Best Interests case conference the following must be clearly recorded;

  1. How the decision about the person’s Best Interests was reached;
  2. What the reasons for reaching the decision were;
  3. Who was consulted to help work out Best Interests; and
  4. What particular factors were taken into account.

Click here to access guidance about how to make a Best Interests decision.

If a decision cannot be made at the Best Interests case conference the following should be recorded;

  1. The reasons why the decision could not be made;
  2. The action that is to be taken following the meeting, in order to ensure that the decision is made.

9. Making Decisions at a Best Interests Case Conference

The circumstances when you can make a decision at a Best Interests case conference, and the process of making a decision are the same as the circumstances and process of making a decision through other means.

Click here to access guidance about when and how to make a Best Interests decision.

10. Implementing the Decision

The process for agreeing how to implement a decision at a Best Interests case conference is the same as the process for agreeing how to implement a decision through other means.

Click here to access guidance for how to implement a Best Interest decision.

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