This outcome is about informed consent. Patients should give consent to their care and treatment, and understand and know how to change decisions about things that have been agreed previously.

Outcome in plain English

2A Manage risk through effective consent procedures

  • If you don't know your patient well, how do you know they can make an informed decision
  • Make information simple to understand
  • If patient can't understand it, explain it to someone more capable
  • Give them time to digest (unless it's an emergency)
  • Respect a child's confidentiality if requested by child
  • Identify adult/parent/guardian when child can't give consent
  • Have a consent procedure for children
  • Patients have the right to bring along an advisor
  • Explain refused treatment and other options
  • Patient can refuse consent or change their mind after consenting
  • The Patient may have made a made decision before becoming mentally impaired/incapacitated
  • Someone might have applied under the Mental Health Act that the patient is not capable of consent. Find out who does.
  • Review consent regularly as patient needs any change from time to time
  • Follow special consent procedures in clinical trials and research

2B Your staff should understand:

  • When consent is needed
  • How to document it
  • When verbal consent is OK
  • Respect and understand cultural differences
  • Be able to provide further help
  • Be sure that patients are capable of giving consent
  • Give the patient sufficient information to make the decision
  • Do what's best for the Patient in emergencies, when it is not possible to obtain consent
  • Ensure previous consent has not changed or been withdrawn
  • Staff should know what to do when:
  • They have to respect decisions even if they disagree
  • What to do when what the Patient wants is not in their best interests
  • When Patient's decision conflicts with the person acting on their behalf
  • How to deal with consent decisions made some time ago
  • Dealing with children's consent

2C You need procedures for when a patient can't or won't give consent

  • See if Mental Health Act or Children Act apply
  • Know the circumstances when previous decisions be lawfully over-ruled
  • What to do in an emergency

2D People who use services benefit from a service that:

  • Takes into account all relevant guidance on consent

2E What does the Patient need to make the decision

  • Patient should be fully informed of pros and cons

2F People who use services give valid consent because:

  • Know that cosmetic surgery can't take place on the same day as the advice (impulse decisions)

2G When symptoms DO NOT indicate Imaging is required:

  • Tell patient of all pros and cons, including:
  • How risky the procedure is
  • Risk if results turn out to be incorrect or are not clear


What the BMA says

Your practice is likely to be compliant if your practice does the following:

  1. Understands and promotes good practice on consent for adults, children and young people.  

  2. Provides information to patients on the care and treatment options available (including the risks and benefits of each option) before they make consent decisions

  3. Understands how written consent should be recorded and when it should be taken, i.e. when:

    - a treatment or procedure is complex, or involves significant risks;
    - the procedure involves 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;
    - the treatment is part of a project or programme of research.

  4. Carries out a regular review of consent decisions to take into account the changing needs of patients.

  5. Can identify when a patient lacks capacity to make their own consent decisions. In those circumstances we suggest that your staff follow the guidance in the BMA’s Mental Capacity Act Toolkit.

  6. Identifies patients who are under 16 years old. In those circumstances we suggest that your staff follow the guidance in the BMA’s Children and Young People Toolkit.  

Your practice has the following:  

  1. A consent policy. You could use the Department of Health’s Model policy for consent to examination or treatment and modify it for your practice. Your staff can also refer to the DH’s Reference guide to consent for examination or treatment.  

  2. Information about your consent procedures on display/available (e.g. a practice notice/leaflet).

Primary Care Networks (PCNs)

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