Policy

Consent to Treatment Policy

Valid consent, capacity assessment and shared decision-making across all regulated activities

For Private Healthcare ClinicRef BS-PH-POL-004See a sample (PDF) →
£54.99
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  • Instant download after checkout
  • Editable Microsoft Word (.docx)
  • Mapped to the CQC standards
  • Optional 3-monthly updates

What's inside

This policy is fully drafted and structured, ready to brand and complete for your service. It covers:

  • 1. Purpose
  • 2. Scope
  • 3. Policy statement
  • 4. Definitions
  • 5. Principles of valid consent
  • 6. The consent process and seeking consent
  • 7. Capacity assessment
  • 8. Adults who lack capacity and best-interests decisions
  • 9. Children and young people
  • 10. Emergencies, refusal and withdrawal of consent
  • 11. Private healthcare specific requirements
  • 12. Specific consent situations
  • 13. Documentation of consent
  • 14. Roles and responsibilities
  • 15. Training
  • 16. Records, monitoring and audit
  • 17. Related documents
  • 18. Version control and review
  • Appendix A: Practitioner consent checklist
  • Appendix B: Capacity and best-interests record (summary)
  • 19. Disclaimer

Legislation & standards it maps to

  • Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 - Regulation 11 (Need for consent), Regulation 9 (Person-centred care), Regulation 10 (Dignity and respect), Regulation 13 (Safeguarding service users from abuse and improper treatment), Regulation 17 (Good governance)
  • Care Quality Commission (Registration) Regulations 2009
  • Mental Capacity Act 2005 and the Mental Capacity Act 2005 Code of Practice (including the Deprivation of Liberty Safeguards)
  • Mental Capacity Act 2005 - Sections 24 to 26 (Advance decisions to refuse treatment)
  • Children Act 1989 and Family Law Reform Act 1969 (consent by under-18s; Gillick competence)
  • Human Rights Act 1998 (Articles 3, 5 and 8)
  • Data Protection Act 2018 and the UK General Data Protection Regulation (Articles 6 and 9 lawful basis for processing)
  • Montgomery v Lanarkshire Health Board [2015] UKSC 11 (informed consent and material risk); General Medical Council, 'Decision making and consent' (2020)

Who it applies to

All clinical and registered staff, locum and agency practitioners, students and trainees, and any contractor or third party involved in assessing, advising, examining or treating patients at [Organisation Name].

Glossary

Plain-English explanations of the technical terms and legislation used in this document.

Advance Decision to Refuse Treatment (ADRT)
A legally binding decision, made in advance by a person with capacity, to refuse a specified treatment in the future should they lose the ability to decide.
Best interests
A decision made for someone who cannot decide for themselves, choosing the option that is best for them.
Capacity (mental capacity)
Whether a person can understand and make a particular decision for themselves at the time it needs to be made.
Care Quality Commission (CQC)
The independent regulator of health and social care services in England.
Chaperone
A trained person present during an intimate examination to support and protect the patient and the clinician.
Court of Protection
The court that makes decisions, and appoints deputies to make decisions, for people who lack the mental capacity to decide for themselves.
Data Protection Act 2018
The UK law that governs how personal information must be handled, sitting alongside the UK General Data Protection Regulation.
Deprivation of Liberty Safeguards (DoLS)
A legal process that protects a person who lacks capacity when restrictions on their care amount to depriving them of their liberty.
Deputy
A person appointed by the Court of Protection to make certain decisions on behalf of someone who lacks the capacity to make them.
Duty of candour
The legal duty to be open and honest with a person and their family when something goes wrong with their care.
Family Law Reform Act 1969
The law that confirms young people aged 16 and 17 can consent to their own medical treatment.
General Medical Council (GMC)
The body that registers doctors in the UK and sets the standards of conduct and practice they must follow.
Gillick competence
The test of whether a child under 16 has enough understanding and maturity to consent to a particular treatment for themselves.
Human Rights Act 1998
The law that gives effect in the UK to basic rights such as the right to life and the right to private and family life.
Human Tissue Act 2004
The law governing the consent needed to remove, store and use human tissue and samples.
Independent Mental Capacity Advocate (IMCA)
An independent advocate who represents and supports a person who lacks capacity and has no one else suitable to speak for them on serious decisions.
Information governance
The framework for handling people's personal and health information legally, securely and appropriately.
Informed consent
Agreement to treatment given freely after the risks, benefits and alternatives have been clearly explained.
Lasting Power of Attorney (LPA)
A legal arrangement letting a person appoint someone they trust to make decisions for them, including about health and welfare, if they later lose capacity.
Material risk
A risk that a reasonable patient, or this particular patient, would think important when deciding whether to agree to a treatment.
Mental Capacity Act 2005
The law that protects and supports people who may be unable to make particular decisions for themselves.
Montgomery v Lanarkshire Health Board
A 2015 Supreme Court case establishing that patients must be told of the material risks and reasonable alternatives to a proposed treatment.
Nominated Individual
The senior person responsible to the regulator for supervising how a service is provided.
Parental responsibility
The legal rights and duties a parent or guardian has for a child, including the ability to consent to the child's treatment.
Registered Manager
The person registered with the regulator as responsible for the day-to-day running of a service.
Regulated activity
A type of care or treatment the law requires a provider to register with the regulator to deliver.
Restraint
The use of force or restriction of movement to stop a person doing something, lawful only when necessary and proportionate to prevent harm.
Safeguarding
Protecting people's health, wellbeing and rights and keeping them safe from abuse, harm or neglect.
Single assessment framework
The structure the regulator uses to judge a service, built around quality statements and five key questions (safe, effective, caring, responsive, well-led).
Special-category data
Sensitive personal information, such as health details, that data-protection law gives extra protection.
UK General Data Protection Regulation (UK GDPR)
The UK's main data-protection law governing how personal information is collected and used.
Valid consent
Permission for care given voluntarily by a person who has capacity and has been given enough information to decide.

How it works

  1. Buy securely with Stripe - instant, no VAT, no account needed.
  2. Download your editable Word file from the link we email you straight away.
  3. Complete the placeholders for your service, then have it approved before use.
  4. Add the optional updates subscription and we keep it current as guidance changes.

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