Consent Policy
Effective From: 12 May 2025
Review Date: 1 June 2026
Approved By: JJ Todd
Author: Clarity/JJ Todd
1. Purpose and definitions
1.1 The purpose of this policy is to provide guidance for staff and assurance to patients that Glenlyn Medical Centre is committed to continually providing high quality healthcare for all patients and supporting the staff who provide this care. The aim of the policy is to provide all staff with an outline of the approach to consent at the practice, the processes involved, and escalation routes, where necessary.
1.2 All patients regardless of age, gender, ethnic background, culture, cognitive function, sexual orientation, or marital status have the right to have their privacy and dignity respected.
1.3 Consent can also be implied, expressed, and informed as described below:
a. Implied consent is described when the actions and rules around a particular setting are well known and understood by all parties. This is the situation, which is usually in place in our practice, when a patient attends to see a clinician.
b. Expressed or explicit consent is in place when the process of explanation and permission is stated and obvious. This can be verbal or written.
c. Informed consent has four elements:
i. The patient must have the capacity to make the decision.
ii. The clinician must provide sufficient information on the examination, treatment, or procedure in question, including the possible benefits and risks, and the chance of each of the benefits or risks.
iii. The patient must be able to comprehend all this information.
iv. The patient must voluntarily grant consent.
1.4 Capacity is the ability of a person to make a decision (or take a particular course of action) at a time when it is needed.
2. Scope
2.1 This policy applies to all employees of Glenlyn Medical Centre, contractors, seconded staff, placements, and agency staff.
3. Roles, rights, and responsibilities
3.1 All staff
a. All staff have a responsibility to:
i. Work with all patients to ensure that they are given the opportunity to consent to examinations, procedures, tests, and investigations.
ii. Ensure that consent is truly informed when required.
iii. Ensure that any consent documentation is accurate, complete, and stored appropriately.
iv. Treat all adults as having capacity until proven otherwise.
v. Assess individual’s capacity on a case-by-case basis (or refer to another competent health professional to provide an assessment).
3.2 Practice management
a. To update the policy, ensure that it is aligned with national guidelines, distribute appropriately, and ensure that staff are trained at induction and at regular intervals so that they are aware of the principles of consent and the content of the practice policy.
b. To ensure that we have a valid and appropriate consent form available for patients and carers.
c. To ensure that we have a secure storage area for retrieval of this information when required.
3.3 Principles of this policy
a. This policy adheres to local and national guidance and policy including the Mental Capacity Act and the professional guidance provided by regulators and the NHS.
b. The Mental Capacity Act (2005) has five key principles:
i. Presumption of capacity — adults should always be presumed to have the capacity to make a decision, unless the healthcare professional can prove otherwise.
ii. Maximizing decision-making capacity — the person must be given all practical support before it can be decided that they lack capacity. Support may involve extra time for assessment, repeating the assessment if capacity fluctuates, or using an interpreter, sign language, or pictures.
iii. The freedom to make seemingly unwise decisions — if the person makes a seemingly unwise decision, this in itself is not proof of incapacity. Proof of incapacity depends on the process by which the decision is made, not the decision itself.
iv. Best interests — any decision or action taken on behalf of the person must be in their best interests. If the decision can be delayed until the person regains capacity, then it should be. A decision taken on another's behalf should take account of their wishes, including those expressed in an advanced decision, and their beliefs and values. The decision-making process should involve, when appropriate, family, carers, and significant others.
v. The least restrictive alternative — when a decision is made on the person's behalf, the healthcare professional must choose the alternative that interferes least with the person's rights and freedoms while still achieving the necessary goal.
3.4 Distribution
a. Employees will be made aware of this policy via TeamNet.
b. Patients will be made aware of this policy using patient leaflets and on the practice website.
3.5 Training
a. All staff will be given training on the concepts and principles of consent at induction and at regular intervals thereafter.
b. Any training requirements will be identified within an individual's Personal Development Reviews. Training is available in the Training module within TeamNet.
4. Equality and diversity impact assessment
4.1 In developing this policy, an equalities impact assessment has been undertaken. An adverse impact is unlikely, and on the contrary the policy has the clear potential to have a positive impact by reducing and removing barriers and inequalities that currently exist.
4.2 If, at any time, this policy is considered to be discriminatory in any way, the author of the policy should be contacted immediately to discuss these concerns.
4.3 Monitoring and reporting
a. Monitoring and reporting in relation to this policy are the responsibility of the practice manager.
b. The following sources will be used to provide evidence of any issues raised:
i. PALS.
ii. Complaints.
iii. Significant and learning events.
4.4 Any incidents relating to consent will be monitored via incident reporting.
5. Summary of NHS legal and mandatory documentation
5.1 Mental Capacity Act 2005 http://www.legislation.gov.uk/ukpga/2005/9/contents
5.2 Mental Capacity Act Code of Practice www.gov.uk/government/publications/mental-capacity-act-code-of-practice