GP mythbuster 49: Consent for minor surgery in GP surgeries

It is vital in all cases that people understand what treatment involves and that they give their consent.

GP practices can offer a range of minor surgery procedures. These range from:

• joint and soft tissue injections

to complex procedures involving:

• incisions and excisions
• aspirations.

When we inspect

We look for evidence that consent to care and treatment always sought in line with legislation and guidance (key line of enquiry E6).

Key principles for consent

The consent is only valid if it is given voluntarily and appropriate information and capacity have been satisfied.

The Royal College of Surgeons (RCS) have produced guidance on consent to use in addition to standards of good medical practice.

The British Association of Dermatologists have produced a guide to validating consent.

The British Medical Association summarised landmark case Montgomery v Lanarkshire Health Board, 2015.

It states doctors must not:

• make assumptions about what a patient needed to know, but must:
• take reasonable care to ensure that the patient is aware of any material risks involved in any treatment, and of any reasonable alternative or variant treatments.

You can find out more about the case, and material risks in the BMA’s consent toolkit for doctors.

The Royal College of Surgeons has described key principles for consent and supported decision making.

The discussion about consent should:

• aim to give the patient information they need to make a decision about what treatment or procedure (if any) they want
• be tailored to the individual patient - this needs time to get to know the patient well enough to understand their views and values
• explain all reasonable treatment options, along with their implications
• include all material risks for each option. This ‘test of materiality’ includes whether
  • in this particular case, a reasonable person in the patient’s position would be likely to attach significance to the risk, or
  • the doctor is or should reasonably be aware that the particular patient would likely attach significance to it.

General Medical Council guidance on consent and making decisions together gives information on:

• assessing capacity
• recording decisions and
• sharing information.

It highlights the importance of providing information the patient can understand. Before beginning treatment, the doctor or a member of the healthcare team should check the patient still wants to go ahead.

The responsibility for consent sits with the doctor undertaking the procedure. If this is not practical, responsibility may be delegated to someone else, provided they:

• are suitably trained and qualified
• have enough knowledge and understanding of the procedure including the risks, and
• understand GMC guidance around consent.

Getting a patient’s written consent

The GMC guidance states:

“in cases that involve higher risk, it is important that you get the patient’s written consent. This is so that everyone understands what was explained and what was agreed.”

The GMC also recommends obtaining written consent from a patient:

“if the investigation or treatment is complex or involves significant risks; or there may be significant consequences for the patient’s employment, or social or personal life.”

Formal written consent may not be needed for relatively minor procedures such as joint injections. It would be needed for more invasive procedures such as skin excision and vasectomy. Where written consent is not obtained it is recommended that the clinician documents in the patient’s clinical record a summary of:

• what was discussed with the patient about the proposed procedure
• any alternative treatment plans
• the likely benefits and risks, and
• an indication that the patient has given consent.

Documenting the consent process

RCS recommends recording the discussion around consent. This includes:

• contemporaneous documentation of key points in the discussion
• hard copies or internet links to any more information given to the patient
• the patient’s decision.

This is also important for patients choosing not to undergo treatment. The GMC recommends documenting any specific requests by the patient.

Getting written consent from a patient is not enough documentation of the consent process. A ‘consent form’ or designated record could be used as a checklist to make sure everything is covered and to record that consent was sought and retained within the patient record.

Minor surgery in GP practices: CQC registration

The regulated activity of surgical procedures does not include minor surgical procedures if they are:

• surgical procedures involving curettage (scraping), cautery (burning) or cryocautery (freezing) of warts, verrucae or other skin lesions carried out using local anaesthesia

Practices offering minor surgical procedures, for example joint injections do not need to register for the surgical procedures regulated activity.

Always refer to the scope of registration when considering what regulated activities to register for.