Duke Street Surgery

4 Duke Street Barrow In Furness Cumbria, LA14 1LF

Practice Policies

Confidentiality

The practice complies with Data Protection and Access to Medical Records legislation. Identifiable information about you will be shared with others in the following circumstances:
• To provide further medical treatment for you e.g. from district nurses and hospital services.
• To help you get other services e.g. from the social work department. This requires your consent.
• When we have a duty to others e.g. in child protection cases
• Anonymised patient information will also be used at local and national level to help the Health Board and Government plan services e.g. for diabetic care.
If you do not wish anonymous information about you to be used in such a way, please let us know.

Reception and administration staff require access to your medical records in order to do their jobs. These members of staff are bound by the same rules of confidentiality as the medical staff.

Your notes
If you wish to see your notes or referral letters please talk to the Practice Manager. Requests for access to any information we hold will be addressed in accordance with the Freedom of Information Act. Should you require copies of your medical records a charge will be made in accordance with national guidelines.

Freedom of Information Policy

The Practice will comply with the Freedom of Information (FoI) Act 2000 and sees it as an opportunity to enhance public trust and confidence in the Practice.

The Practice will maintain a comprehensive ‘Publication Scheme’ (in line with the Information Commissioner’s Office Model Publication Scheme)
https://ico.org.uk/media/for-organisations/documents/1153/model-publication-scheme.pdf that provides information which is readily accessible without the need for a formal FoI Act request.

The Practice will seek to satisfy all FoI Act requests promptly and within 20 working days. However, if necessary we will extend this timescale to give full consideration to a Public Interest test. If we do not expect to meet the deadline, we will inform the requester as soon as possible of the reasons for the delay and when we expect to have made a decision.

The Practice will continue to protect the personal data entrusted to us, by disclosing it only in accordance with the Data Protection Act 1998.

The Practice will provide advice and assistance to requesters to facilitate their use of FoI Act. We will publish our procedures and assist requesters to clarify their requests so that they can obtain the information that they require.

The Practice will liaise with the Cumbria CCG and other bodies with whom we work to ensure that we can meet our FoI Act obligations, including the disclosure of any information that they hold on our behalf.

The Practice will apply the exemptions provided in the FoI Act and, where qualified exemptions exist, the Practice will disclose the information unless the balance of public interest lies in withholding it.

The Practice will consult with third parties before disclosing information that could affect their rights and interests. However, according to the FoI Act, the Practice must take the final decision on disclosure.

The Practice will charge for information requests in line with the FoI Act Fees Regulations or other applicable regulations, including the Data Protection Act 1998.

The Practice will record all FoI Act requests and our responses and will monitor our performance in handling requests and complaints.

The Practice will ensure that all staff are aware of their obligations under FoI Act and will include FoI Act education in the induction of all new staff

Named GP

All patients have a named GP who is responsible for their overall care at the practice. Please contact the practice if you wish to know who this is, and if you have a preference as to which GP it is. The practice will make reasonable efforts to accomodate this request.

Access to Medical Records Policy

For the purposes of the Data Protection Act 1998, a health or medical record is a record which :

• ‘consists of information relating to the physical or mental health or condition of an individual and;
• has been made by or on behalf of a health professional in connection with the care of that individual.’

Patients have the right to ask for a copy of their medical records or to view part of their records.

If a patient makes an enquiry regarding this, they must be advised that:
• They should complete the form ‘ Request for Medical Records’, available from Reception, A fee will be charged. This will normally be £10 for a full copy of the computerised record and £50 for a full copy including computerised and paper notes.
• The Practice will provide this within 40 days
• The patient will be required to prove their identity when collecting the notes.
• If the patient wishes to view their record, this can be arranged by speaking to the Practice Manager and an appropriate time will be agreed.
• Advise the patient to inform us if they believe anything in their record is inaccurate or incorrect.

More detailed information can be found in the Information Commissioner’s Office ‘Subject Access’ Code of Practice.
www.ico.org.uk

Complaints

We make every effort to give the best service possible to everyone who attends our practice.

However, we are aware that things can go wrong resulting in a patient feeling that they have a genuine cause for complaint. If this is so, we would wish for the matter to be settled as quickly, and as amicably, as possible.

To pursue a complaint please contact the practice manager who will deal with your concerns appropriately. Further written information is available regarding the complaints procedure from reception.

NHS_complaints_guidance_leaflet

Zero Tolerance

Incident Definition
Any incident where staff perceive they, or their colleagues, have been abused, threatened or assaulted in circumstances related to their work, involving an explicit or implicit challenge to their safety, well being or health.

A risk assessment will be carried out on an annual basis focussing on support for staff. This will be followed up on risk control for all identified points.

Any issues and/or critical incidents will be discussed at the monthly reception meeting.

Dr. Wear is the doctor responsible for co-ordinating the violence policy in the Practice

A Statement on zero tolerance is displayed in the waiting room

This policy is also produced as a patient information leaflet which will be brought to the attention of all new patients and inserted in the Practice Leaflet.

The Practice Procedure is –

(a) complaint received from staff member following an incident

(b) incident form completed

(c) An interview to take place with the patient(s) involved, the doctor and the Practice Manager

(i) A meeting will take place involving all the Practice staff which will include he decision or otherwise to keep a patient on the list or alternative ways of seeing the patient in the surgery.

If, after discussion, any single member of staff feels they want the patient removed from the list, then this takes precedence over everything else.

(d) A decision will then be given to the patient

(e) An entry will be made on the patient’s computer record

(f) Every incident, including verbal abuse, will be reported to the Health Authority and where appropriate to the police.

Patients should be aware that –

 Subsequent incidents may lead to removal from the list

 Serious incidents will lead to immediate removal from the list.

Receptionists Role

 Try to be positive, always offer the patient something rather than outright refusal.

 Refer the aggressive or aggrieved patient to a more senior member of staff rather than entering into arguments

 Don’t exceed one’s responsibility by appearing to make inapropriate judgements about patients’ needs

 Respect the dignity of all patients and befriend the vulnerable ones.

Patient Chaperone Policy

Introduction
This policy is designed to protect both patients and staff from abuse or allegations of abuse and to assist patients to make an informed choice about their examinations and consultations.

Guidelines
Clinicians (male and female) should consider whether an intimate or personal examination of the patient (either male or female) is justified, or whether the nature of the consultation poses a risk of misunderstanding.

• The clinician should give the patient a clear explanation of what the examination will involve.

• Always adopt a professional and considerate manner – be careful with humour as a way of relaxing a nervous situation as it can easily be misinterpreted.

• Always ensure that the patient is provided with adequate privacy to undress and dress.

• Ensure that a suitable sign is clearly on display in each consulting or treatment room offering the chaperone service if required.

This should remove the potential for misunderstanding. However, there will still be times when either the clinician, or the patient, feels uncomfortable, and it would be appropriate to consider using a chaperone. Patients who request a chaperone should never be examined without a chaperone being present.
IF NECESSARY, WHERE A CHAPERONE IS NOT AVAILABLE, THE CONSULTATION/EXAMINATION SHOULD BE REARRANGED FOR A MUTUALLY CONVENIENT TIME WHEN A CHAPERONE CAN BE PRESENT.

ALL PATIENTS UNDER 16 YEARS OF AGE MUST HAVE A CHAPERONE. The potential for misunderstanding and anxiety during a personal examination is higher in younger people.

Complaints and claims have not been limited to male doctors with female patients – there are many examples of alleged homosexual assault by female and male doctors. Consideration should also be given to the possibility of a malicious accusation by a patient. There may be rare occasions when a chaperon is needed for a home visit.

Who can act as a chaperone?
Only fully trained staff can act as a chaperone, where possible, it is strongly recommended that chaperones should be clinical staff familiar with procedural aspects of personal examination. Where suitable clinical staff members are not available the examination should be deferred.

Where the practice determines that non-clinical staff will act in this capacity the patient must agree to the presence of a non-clinician in the examination, and be at ease with this. The staff member should be trained in the procedural aspects of personal examinations, comfortable in acting in the role of chaperone, and be confident in the scope and extent of their role. They will have received instruction on where to stand and what to watch and instructions to that effect will be laid down in writing by the practice.

Confidentiality
• The chaperone should ONLY BE PRESENT FOR THE EXAMINATION ITSELF, and most discussion with the patient should take place while the chaperone is not present.

• Patients should be reassured that all practice staff understand their responsibility not to divulge confidential information.

Procedure
• The clinician will contact reception to request a chaperone.

• The clinician will record in the notes that the chaperone is present, and identify the chaperone.

• Where no chaperone is available the examination will not take place – the patient should not normally be permitted to dispense with the chaperone once a desire to have one present has been expressed.

• The chaperone will enter the room discreetly and remain in the room until the clinician has finished the examination.

• The chaperone will normally attend inside the curtain at the head of the examination couch and watch the procedure.

• To prevent embarrassment, the chaperone should not enter into conversation with the patient or GP unless requested to do so, or make any mention of the consultation afterwards.

• The chaperone will make a record in the patient’s notes after examination. The record will state that there were no problems, or give details of any concerns or incidents that occurred.

• The patient can refuse a chaperone, and if so this must be recorded in the patient’s medical record.

Information Governance Policy

Summary
Information is a vital asset, both in terms of the clinical management of individual patients and the efficient management of services and resources. It plays a key part in clinical governance, service planning and performance management.

It is therefore of paramount importance to ensure that information is efficiently managed, and that appropriate policies, procedures and management accountability provide a robust governance framework for information management.

The implementation information governance is designed to improve the service to patients and ensure their safety and well-being. It applies to all members of the clinical team supported by ancillary and attached staff.

Principles
The Practice recognises the need for an appropriate balance between openness and confidentiality in the management and use of information. The Practice fully supports the principles of corporate governance and recognises its public accountability, but equally places importance on the confidentiality of, and the security arrangements to safeguard, both personal information about patients and staff and commercially sensitive information. The Practice also recognises the need to share patient information with other health organisations and other agencies in a controlled manner consistent with the interests of the patient and, in some circumstances, the public interest. The practice also recognises, and works within the computer misuse act.

Computer Misuse Act
The computer misuse act 1990 established three prosecutable offences against unauthorised access to any software or data held on any computer. The offences are:
• Unauthorised access to computer material
• Unauthorised access with intent to commit or facilitate the commission of further offences
• Unauthorised modification of computer material

The Practice believes that accurate, timely and relevant information is essential to deliver the highest quality health care. As such it is the responsibility of all clinicians and managers to ensure and promote the quality of information and to actively use information in decision making processes.

There are 4 key interlinked strands to the information governance policy:

• Openness
• Legal compliance
• Information security
• Quality assurance

Openness
• Non-confidential information on the Practice and its services should be available to the public through a variety of media, in line with the Practice’s code of openness
• The Practice will establish and maintain policies to ensure compliance with the Freedom of Information Act
• The Practice will undertake or commission annual assessments and audits of its policies and arrangements for openness
• Patients should have ready access to information relating to their own health care, their options for treatment and their rights as patients
• The Practice will have clear procedures and arrangements for liaison with the press and broadcasting media
• The Practice will have clear procedures and arrangements for handling queries from patients and the public

Legal Compliance
• The Practice regards all identifiable personal information relating to patients as confidential
• The Practice will undertake or commission annual assessments and audits of its compliance with legal requirements
• The Practice regards all identifiable personal information relating to staff as confidential except where national policy on accountability and openness requires otherwise
• The Practice will establish and maintain policies to ensure compliance with the Data Protection Act, Human Rights Act and the common law confidentiality
• The Practice will establish and maintain policies for the controlled and appropriate sharing of patient information with other agencies, taking account of relevant legislation (e.g. Health and Social Care Act, Crime and Disorder Act, Protection of Children Act)

Information Security
• The Practice will establish and maintain policies for the effective and secure management of its information assets and resources
• The Practice will undertake or commission annual assessments and audits of its information and IT security arrangements
• The Practice will promote effective confidentiality and security practice to its staff through policies, procedures and training
• The Practice will establish and maintain incident reporting procedures and will monitor and investigate all reported instances of actual or potential breaches of confidentiality and security

Smartcards
• Use your Smartcard responsibly and in line with your access rights.
• Inform the Practice Manager immediately should your Smartcard be lost, stolen or misplaced.
• Ensure that you report any misuse of the Smartcards
• Ensure that you keep your Smartcard and log-in details confidential. In particular you must not leave your PC logged in and you must not share or provide access to your Smartcards or passwords.
• Ensure that you accurately complete the necessary paperwork, provides suitable identification and attends any appropriate appointments in order to register on the system or have your Smartcard updated/re-issued.
• All members of staff using Smartcards should follow the organisation’s suite of Information Governance policies and procedures; adhere to the Data Protection and Caldicott Principles, and the Confidentiality Code of Practice and the Care Records Guarantee.

Information Quality Assurance
• The Practice will establish and maintain policies and procedures for information quality assurance and the effective management of records
• The Practice will undertake or commission annual assessments and audits of its information quality and records management arrangements
• Managers are expected to take ownership of, and seek to improve, the quality of information within their services
• Wherever possible, information quality should be assured at the point of collection
• Data standards will be set through clear and consistent definition of data items, in accordance with national standards.
• The Practice will promote information quality and effective records management through policies, procedures/user manuals and training

POLICY
Patient involvement: We will seek patient participation and provide patients with the mechanism to feedback and suggest.

Clinical Audit: We will undertake regular clinical audits, record the results, and plan improvements to patient benefit. We will also undertake audit of administrative procedures to ensure that they are working effectively.

Evidence-based medical treatment: We will maintain an up to date knowledge of current developments and research and assess these against established and proven methods of working. We will share expertise and opinion within the practice and between clinicians to promote learning and discussion.

Staff and staff management: We will encourage team working across the practice, establish a “no-blame” learning culture, and provide an open and equal working relationship with colleagues. We will seek to work to an “Investor in People” standard and support training, development, devolution of control and empowerment.

Information and its use: We will make full use of information both electronic and paper-based in clinical and non-clinical decision making. We will share best practices with others both inside and outside the practice. We will seek to improve data quality and encourage patients to participate in their own clinical treatment, their records, and decisions which affect them.

Risk control: We will operate a free system of Significant Event Reporting to encourage review, feedback and learning from incidents in an open and no-blame culture. All significant events will be discussed and documented within the forum of a clinical review / policy meeting.

Continuing Professional Development (CPD): We will ensure CPD via full participation in appraisal, revalidation, attendance at training events, and the organisation of regular in-house clinical seminars from specialist consultants. All development activity will be documented as part of individual learning portfolios. Non-clinical staff will be encouraged to attend events related to their own specialism or professional development needs, and it is not intended that this will be cash-limited.

Patient experience: We will discuss feedback received from patients and publicise both suggestions and the practice response. Where individuals are identifies they will receive a personal response. We will view the practice from the patient perspective (in particular from formal patient survey results) and actively seek to implement feasible and beneficial ideas.

IMPLEMENTATION
Dr Ian Wear and Laura Hodgkinson are the Clinical Governance leads for the practice. They are responsible for –

• Promotion of quality care within the practice
• Provide clinical governance leadership and advice
• Keeping up to date with research and governance recommendations, and communicating these accordingly
• To act as an expert resource and advisor in the examination and review of significant events
• To initiate and review clinical audits
• To oversee the management of the key Policy provisions above

Calidcott Guardian: Laura Hodgkinson
Data Protection Officers: Leanne Johnston & Kate Farley

Patients have a fundamental legal and ethical right to determine what happens to their own bodies. Valid consent to treatment is therefore absolutely central in all forms of health care, from providing personal care to undertaking major surgery. Seeking consent is also a matter of common courtesy between health professionals and patients.

“Consent” is a patient’s agreement for a health professional to provide care. Patients may indicate consent non-verbally (for example by presenting their arm for their pulse to be taken), orally, or in writing. For the consent to be valid, the patient must:

• Be competent to take the particular decision.

• Have received sufficient information to take it; and

• Not be acting under duress.

The context of consent can take many different forms, ranging from the active request by a patient of a particular treatment (which may or may not be appropriate or available) to the passive acceptance of a health professional’s advice. In some cases, the health professional will suggest a particular form of treatment or investigation and after discussion the patient may agree to accept it. In others, there may be a number of ways of treating a condition, and the health professional will help the patient to decide between them. Some patients, especially those with chronic conditions, become very well informed about their illness and may actively request particular treatments. In many cases “seeking consent” is better described as “joint decision making”: the patient and health professional need to come to an agreement on the best way forward, based on the patient’s values and preferences and the health professional’s clinical knowledge.

Where an adult patient lacks the mental capacity (either temporarily or permanently) to give or withhold consent for themselves, no one else can give consent on their behalf. However, treatment may be given if it is in their best interests, as long as it has not been refused in advance in a valid and applicable advance directive.

For significant procedure, it is essential for health professionals to document clearly both a patient’s agreement to the intervention and the discussions which led up to that agreement through documenting it in the patient’s notes that they have given oral consent.

WRITTEN CONSENT
Consent is often wrongly equated with a patient’s signature on a consent form. A signature on a form is evidence that the patient has given consent, but is not proof of valid consent. If a patient is rushed into signing a form, on the basis of too little information, the consent may not be valid, despite the signature. Similarly, if a patient has given valid verbal consent, the fact that they are physically unable to sign the form is no bar to treatment. Patients may, if they wish, withdraw consent after they have signed a form: the signature is evidence of the process of consent giving, not a binding contract.

It is rarely a legal requirement to seek written consent, but it is good practice to do so if any of the following circumstances apply:

The treatment or procedure is complex, or involves significant risks (the term “risk” is used throughout to refer to any adverse outcome, including those, which some health professionals would describe as “side effects” or “complications”)

The procedure involves general/regional anaesthesia or sedation.

Providing clinical care is not the primary purpose of the procedure.

There may be significant consequences for the patient’s employment, social or personal life.

Completed forms should be scanned onto computer record. Any changes to a form, made after the patient has signed the form, should be initialled and dated by both the patient and health professional.

It will not usually be necessary to document a patient’s consent to routine and low-risk procedures, such as providing personal care or taking a blood sample. However, if you have any reason to believe that the consent may be disputed later or if the procedure is of particular concern to the patient (for example if they have declined, or become very distressed about similar care in the past) it would be helpful to do so.

Procedures to follow when patients lack capacity to give or withhold consent
Where an adult patient does not have the capacity to give or withhold consent to a significant intervention, this fact should be documented in Form 4 (form for adults who are unable to consent to investigation or treatment), along with the assessment of the patient’s capacity, why the health professional believes the treatment to be in the patient’s best interests, and the involvement of people close to the patient. The standard consent forms should never be used for adult patients unable to consent for themselves. For more minor interventions, this information should be entered in the patient’s notes.

An apparent lack of capacity to give or withhold consent may in fact be the result of communication difficulties rather than genuine incapacity. You should involve appropriate colleagues in making such assessments of incapacity, such as specialist learning disability teams and speech and language therapists, unless the urgency of the patient’s situation prevents this. If at all possible, the patient should be assisted to make and communicate their own decision, for example by providing information in non-verbal ways where appropriate.

Occasionally, there will not be a consensus on whether a particular treatment is in an incapacitated adult’s best interests. Where the consequences of having, or not having the treatment are potentially serious, a court declaration may be sought.

When should consent be sought?
When a patient formally gives their consent to a particular intervention, this is only the endpoint of the consent process. It is helpful to see the whole process of information provision, discussion and decision making as part of “seeking consent”. This process may take place at one time, or over a series of meetings and discussions, depending on the seriousness of what is proposed and the urgency of the patient’s condition.

Single stage process
In many cases it will be appropriate for a health professional to initiate a procedure immediately after discussing it with the patient.

While administrative arrangements will vary, it should always be remembered that for consent to be valid the patient must feel that it would have been possible for them to refuse, or change their mind. It will rarely be appropriate to ask a patient to sign a consent form after they have begun to be prepared for treatment (for example, by changing into a hospital gown), unless this is unavoidable because of the urgency of the patient’s condition.

Treatment of young children
Only people with “parental responsibility” are entitled to give consent on behalf of their children. You must be aware that not all parents have parental responsibility for their children (for example, unmarried fathers do not automatically have such responsibility although they may acquire it). If you are in any doubt about whether the person with the child has parental responsibility for that child, you must check.

Provision of Information
The provision of information is central to the consent process. Before patients can come to a decision about treatment, they need comprehensible information about their condition and about possible treatments/investigations and their risks and benefits (including the risks/benefits of doing nothing).

Patients and those close to them will vary in how much information they want: from those who want as much detail as possible, including details of rare risks, to those who ask health professionals to make decisions for them. There will always be an element of clinical judgement in determining what information should be given. However, the presumption must be that the patient wishes to be well informed about the risks and benefits of the various options. Where the patient makes clear (verbally or non-verbally) that they do not wish to be given this level of information, this should be documented.

Provision for patients whose first language is not English
This practice is committed to ensuring that patients whose first language is not English receive the information they need and are able to communicate appropriately with health care staff. It is not appropriate to use children to interpret for family members who do not speak English.

Access to health professionals between formal appointments
After an appointment with a health professional patients will often think of further questions which they would like answered before they take their decision.

Who is responsible for seeking consent?

The health professional carrying out the procedure is ultimately responsible for ensuring that the patient is genuinely consenting to what is being done. It is they who will be held responsible in law if this is challenged later.

Where oral or non-verbal consent is being sought at the point the procedure will be carried out, this will naturally be done by the health professional responsible. However, team work is a crucial part of the way the NHS operates, and where written consent is being sought it may be appropriate for other members of the team to participate in the process of seeking consent.

Completing consent forms
The standard consent form provides space for a health professional to provide information to patients and to sign confirming that they have done so. The health professional providing the information must be competent to do so: either because they themselves carry out the procedure, or because they have received specialist training in advising patients about this procedure, have been assessed, are aware of their own knowledge limitations and are subject to audit.

If the patient signs the form in advance of the procedure (for example in out-patients or at a pre-assessment clinic), a health professional involved in their care on the day should sign the form to confirm that the patient still wishes to go ahead and has had any further questions answered. It will be appropriate for any member of the health care team (for example a nurse admitting the patient for elective procedure) to provide the second signature, as long as they have access to appropriate colleagues to answer questions they cannot handle themselves.

Insert local details, where appropriate at Directorate level covering:

what training is available for health professionals who do not themselves carry out specific procedures, but could potentially provide the information patients need in coming to a decision.

what procedures are in place to ensure that the health professionals “confirming” the patient’s consent have genuine access to appropriate colleagues where they are personally not able to answer any remaining questions.

Responsibility of health professionals
It is a health professional’s own responsibility:

to ensure that when they require colleagues to seek consent on their behalf they are confident that the colleague is competent to do so; and

to work within their own competence and not to agree to perform tasks which exceed that competence.

If you feel you are being pressurised to seek consent when you do not feel competent to do so (insert local details of whom to contact, such as clinical governance lead).

Refusal of treatment
If the process of seeking consent is to be a meaningful one, refusal must be one of the patient’s options. A competent adult patient is entitled to refuse any treatment, except in circumstances governed by the Mental Health Act 1983. The situation for children is more complex: see the Department of Health’s Seeking Consent: working with children for more detail. The following paragraphs apply primarily to adults.

If, after discussion of possible treatment options, a patient refuses all treatment, this fact should be clearly documented in their notes. If the patient has already signed a consent form, but then changes their mind, you (and where possible the patient) should note this on the form.

Where a patient has refused a particular intervention, you must ensure that you continue to provide any other appropriate care to which they have consented. You should also ensure that the patient realises they are free to change their mind and accept treatment if they later wish to do so. Where delay may affect their treatment choices, they should be advised accordingly.

If a patient consents to a particular procedure but refuses certain aspect of the intervention, you must explain to the patient the possible consequences of their partial refusal. If you genuinely believe that the procedure cannot be safely carried out under the patient’s stipulated conditions, you are not obliged to perform it. You must, however, continue to provide any other appropriate care. Where another health professional believes that the treatment can be safely carried out under the conditions specified by the patient you must on request be prepared to transfer the patient’s care to that health professional.

Clinical photography and conventional or digital video recording

Photographic and video recordings made for clinical purposes form part of a patient’s record.

If you wish to make a photographic or video recording of a patient specifically for education, publication or research purposes, you must first seek their written consent (or where appropriate that of a person with parental responsibility) to make the recording, and then seek their consent to use it. Patients must know that they are free to stop the recording at any time and that they are entitled to view it if they wish, before deciding whether to give consent to its use. If the patient decides that they are not happy for any recording to be used, it must be destroyed. As with recordings made with therapeutic intent, patients must receive full information on the possible future uses of the recording, including the fact that it may not be possible to withdraw it once it is in the public domain.

ENGLISH LAW – 12 KEY POINTS

When do health professionals need consent from patients?
Before you examine, treat or care for competent adult patients you must obtain their consent. Adults are always assumed to be competent unless demonstrated otherwise. If you have doubts about their competence, the question to ask is “Can this patient understand and weigh up the information needed to make this decision?” Unexpected decisions do not prove the patient is incompetent, but may indicate a need for further information or explanation.

Patients may be competent to make some health care decisions, even if they are not competent to make others. Giving and obtaining consent is usually a process, not a one-off event. Patients can change their minds and withdraw consent at any time. If there is any doubt, you should always check that the patient still consents to your caring for or treating them.

Can children give consent for themselves?
Before examining, treating or caring for a child you must also seek consent. Young people aged 16 and 17 are presumed to have the competence to give consent for themselves. Younger children who understand fully what is involved in the proposed procedure can also give consent (although their parents will ideally be involved). In other cases, some-one with parental responsibility must give consent on the child’s behalf, unless they cannot be reached in an emergency. If a competent child consents to treatment, a parent cannot over-ride that consent. Legally, a parent can consent if a competent child refuses, but it is likely that taking such a serious step will be rare.

Who is the right person to seek consent?
It is always best for the person actually treating the patient to seek the patient’s consent. However, you may seek consent on behalf of colleagues if you are capable of performing the procedure in question, or if you have been specially trained to seek consent for that procedure.

What information should be provided?
Patients need sufficient information before they can decide whether to give their consent: for example information about the benefits and risks of the proposed treatment, and alternative treatments. If the patient is not offered as much information as they reasonably need to make their decision, and in a form they can understand, their consent may not be valid. Consent must be given voluntarily: not under any form of duress or undue influence from health professionals, family or friends.

Does it matter how the patient gives consent?
No: consent can be written, oral or non-verbal. A signature on a consent form does not itself prove the consent is valid – the point of the form is to record the patient’s decision, and also increasingly the discussions that have taken place. Your Trust or organisation may have a policy setting out when you need to obtain written consent.

Refusal of treatment
Competent adult patients are entitled to refuse treatment, even when it would clearly benefit their health. The only exception to this rule is where the treatment is for a mental disorder and the patient is detained under the Mental Health Act 1983. A competent pregnant woman may refuse any treatment, even if this would be detrimental to the fetus.

Adults who are not competent to give consent.
No-one can give consent on behalf of an incompetent adult. However, you may still treat such a patient if the treatment would be in their best interests. “Best interests” go wider than best medical interests, to include factors such as the wishes and beliefs of the patient when competent, their current wishes, their general well being and their spiritual and religious welfare. People close to the patient may be able to give you information on some of these factors. Where the patient has never been competent, relatives, carers and friends may be best placed to advise on their patient’s needs and preferences.

If an incompetent patient has clearly indicated in the past, while competent, that they would refuse treatment in certain circumstances (an “advance refusal”), and those circumstances arise, you must abide by that refusal.