Consent policy

Clinically Sound Ltd (CSL) provides remote General Practice and as such does not examine patients face to face, however it does assess patient’s symptoms, formulate diagnoses and instigates investigations, treatments and or referrals to other clinicians. As such it is recognised that consent of the Adult and /or child must be obtained prior to any proposed care or treatment plans.

Adults are assumed to be competent unless demonstrated otherwise. The question ‘Can this patient understand and weigh up the information needed to make this decision’ is to be asked. Unexpected decisions do not prove the patient incompetent but may indicate the need for further information or explanation.

Children – consent must also be obtained before any assessment or treatment process.

Young people aged 16 and 17 are presumed, like adults, to have the capacity to consent for themselves.

Younger children who demonstrate that they fully understand the proposed clinical involvement can also give consent, so called ‘Gillick or Fraser competence’ (preferably with their parents involved also) In other cases someone with parental responsibility must give consent on the child’s behalf.

If a competent child gives consent a parent cannot override this decision.

Giving and obtaining consent is a process not a one off event and patients can change their minds and withdraw consent at any time.

Ideally consent will be gained by the clinician who is actually managing the care of the patient. 

Consent can be written, verbal or non verbal and must be obtained after the patient has sufficient information to decide to give or not their consent. Consent must be given voluntarily and freely without pressure or duress. 

Competent adults are entitled to refuse treatment, even where it would clearly benefit their health. 

No one can give consent on behalf of an incompetent adult, however a clinician may still treat such a patient if the treatment would be in their best interests. Relatives, carers and friends may be best placed to advise on patients needs and preferences. In the case of an incompetent adult who used to have capacity and would have at that time refused treatments (advanced refusal) and those circumstances have arisen then their prior wishes must be respected. 

The Mental Capacity Act 2005 provides the legal framework for acting and making decisions on behalf of individuals who lack the mental capacity to make particular decisions for themselves.  The apparent lack of capacity to give or withhold consent may be as a result of communication difficulties rather than actual incapacity. All avenues to support communication needs must be exhausted. 

If someone is deemed as having no capacity to consent then consent can be sought from an adult who has Legal Power of Attorney ,Health and welfare. Or failing that then it is possible to instruct an Independent Mental Capacity Advocate (IMCA) if serious medical treatment is required.

CSL will record consent in a patient’s records were appropriate to do so.