Sample policy · Independent specialist doctor

Consent and shared decision-making policy (independent specialist doctor)

Statutory anchor: Regulation 11 (need for consent), Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (SI 2014/2936). This policy also engages the Mental Capacity Act 2005, the Montgomery v Lanarkshire standard of material risk, and GMC consent guidance. · primary source

1. What the regulation says

Care and treatment of service users must only be provided with the consent of the relevant person. (Reg 11(1): the headline duty)

The full text of the regulation is at https://www.legislation.gov.uk/uksi/2014/2936/regulation/11. Where this policy and the regulation diverge, the regulation wins.

2. Plain-English summary

You can only provide care or treatment with the consent of the relevant person. If the service user is 16 or over and lacks capacity, follow the Mental Capacity Act 2005. If Parts 4 or 4A of the Mental Health Act 1983 apply, follow that instead. Section 5 of the MCA (acts done in connection with care or treatment) still applies underneath.

3. Purpose

A single-handed independent specialist makes decisions with patients who are often paying privately and who may feel a procedure is expected once they have come this far. Good consent means a genuine, shared decision based on the patient's own goals, with the material risks and the alternatives, including doing nothing, set out honestly, and free from any pressure created by the doctor's financial interest in proceeding. This policy sets out how the practice takes consent and shares decisions.

The practice must verify this policy against current GMC consent guidance and the Montgomery standard of material risk before adoption.

4. Sources to verify before adoption

5. Scope

This policy applies to:

6. Roles and responsibilities

7. Consent and shared-decision procedure

The practice follows this procedure for each treatment, procedure or investigation:

  1. Confirm the decision being made. Identify the exact treatment, procedure, test or course of action, and whether it is urgent, elective, cosmetic, diagnostic, invasive or repeat care.
  2. Check capacity and communication needs. Start from the presumption that the adult patient has capacity, then check whether they need support, reasonable adjustments, an interpreter, accessible information, more time, an advocate or a best-interests process.
  3. Find out what matters to the patient. Ask about the patient's goals, concerns, lifestyle, work, caring responsibilities, previous experience, cost concerns and the outcomes they would find unacceptable.
  4. Explain options honestly. Explain the recommended option, reasonable alternatives, the likely result of each, and the option of doing nothing or waiting.
  5. Discuss material risks. Cover risks a reasonable person in the patient's position would want to know, and risks that matter to this individual patient.
  6. Check understanding. Give time for questions, use plain language, and check that the patient has understood the main benefits, risks, alternatives and uncertainties.
  7. Manage pressure and conflicts. Make costs clear before treatment, avoid same-day pressure for elective irreversible procedures unless clinically justified, and make clear that the patient can decline or change their mind.
  8. Record the decision. Record the conversation, the patient's questions, the information given, the options declined, capacity findings where relevant, and the decision reached.
  9. Review consent when things change. Revisit consent if the plan, risk profile, patient's wishes, capacity, price, clinician, setting or timing changes.
  10. Escalate concerns. If the patient may lack capacity, appears coerced, raises safeguarding concerns, has a serious adverse outcome, or complains about consent, pause where safe and escalate through the relevant safeguarding, incident, complaints or governance route.

8. A shared decision

Consent is a conversation, not a form. For each decision the doctor:

9. Honesty about benefit and alternatives

10. Financial interest and no pressure

Because the practice has a financial interest in providing treatment, the practice is careful that this never influences the advice:

11. Time to decide for elective treatment

For elective treatment the patient is given time between the discussion and the procedure to reflect, is told they can change their mind at any point, and is not booked for an irreversible elective procedure on the same day as the first consultation unless there is a clinical reason.

12. Capacity

Where a patient may lack the capacity to make a decision, the practice follows the Mental Capacity Act: capacity is assessed for that decision, the patient is given all practicable help to decide, and where they cannot, a best-interests decision is made and recorded, involving those close to the patient and an advocate where the patient has no one to represent them.

13. Recording

The consent discussion, the options and risks covered, the patient's questions, the fee information given, and the patient's decision are recorded. The signed form is part of the record, not the whole of it.

14. Records and register links

The consent record should include:

Consent concerns raised through complaints are tracked in the complaints register. Consent-related harm, near misses or missing records are reviewed through the incident register. Repeated gaps are added to the risk register or improvement-actions register and reviewed at the governance meeting.

15. Training and competence

The doctor must remain up to date with GMC consent guidance, Mental Capacity Act duties, material-risk case law, communication adjustments and the procedures offered by the practice. Support staff who give patient information or arrange procedures must understand that they cannot obtain clinical consent unless competent and authorised to do so.

Training records are held in the training matrix. Consent themes from complaints, incidents, record audits and patient feedback are used for continuing professional development and peer review.

16. Audit cadence

The practice checks, on a stated cadence, that:

The doctor and the Registered Manager review the results and record the improvement actions that follow.

17. Sources and further reading

This template is based on CQC's guidance for providers and managers, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and other topic-specific legislation and guidance listed below. It is a starting point for adaptation, not a substitute for legal, clinical, HR, safeguarding or specialist professional advice.

18. Related reading

19. When to seek further advice

Seek specialist advice where the issue involves serious harm, safeguarding, deprivation of liberty, restraint, children, professional misconduct, controlled drugs, radiation, termination of pregnancy, infection outbreak, water safety, employment dismissal, DBS barring referral, or regulatory enforcement.

20. Document control

Version Date Author Changes
v1.1 2026-07-12 Verivius (sample) Added role ownership, consent procedure, evidence fields, register links, training and competence controls, and related reading.
v1 2026-06-10 Verivius (sample) Conformed to the Verivius policy standard: added statutory anchor, verbatim regulation quote, plain-English summary, sources and further reading, and document control. Original operational sections preserved.

This sample policy template was issued by Verivius. It is a template, not a substitute for legal advice or the tenant's own policy-development process. Where this template and live law or regulator guidance diverge, the live source wins.

What good looks like here

Written from an ex-CQC inspector's chair, but the point is safe, well-led care your team can stand behind. Each row shows what strong evidence looks like, what thin evidence looks like, and where the expectation comes from.

A single-handed independent specialist is both the person advising on the treatment and the person paid for it, and the patient has usually travelled, already paid for the consultation, and arrived half expecting to go ahead. That combination is what makes consent here a clinical safety matter rather than paperwork. The real risk is not an unsigned form. It is that the more conservative option, the option of waiting, and care the practice does not itself provide are never genuinely put on the table, so the patient chooses from a shorter list than the one that actually exists. Someone who heard the realistic chance of benefit, the risks that bear on their particular job or family situation, and the cost, before anything irreversible happened, makes a different decision from someone read a standard risk list at the door of the treatment room. The consent record is the only thing that later shows which of those two conversations took place. That protects the patient first, and it is also what stands behind the doctor when an outcome is poor but the decision was sound. Where the record is a signed form and nothing else, neither the patient nor anyone reviewing the care afterwards can tell the two apart.

  1. The consent record shows a real, person-specific conversation: the options including doing nothing, the alternatives, and the patient's own questions, rather than a signed form standing in for the discussion. What goes wrong is a consent form on file with no note of what was actually said, so nobody picking the record up later can tell what the patient was choosing between.

    Strong evidence: The consent record: information given about benefits, risks, uncertainties, alternatives and no treatment, what mattered to the patient, and the questions asked and answered, audited to confirm the record is not a generic form; the signed form is part of the record, not the whole of it (section 13, section 14, procedure steps 4 to 8, Audit cadence).

    Weak evidence: A pre-printed consent form carrying the procedure name and a signature, filed with no clinical note of what was actually discussed, or the same three-line entry ("risks and benefits explained, patient happy to proceed") repeated word for word across different patients having different procedures. The tell is a record in which the patient's own questions, the option of doing nothing, and the alternatives that were declined never appear anywhere.

    The recognised standard from a professional or clinical body, such as NICE or a royal college. Not a legal duty, but the accepted mark of safe practice, and a departure needs a documented reason.

  2. The material risks discussed are those a reasonable patient in this person's position would want to know, plus any that matter to this individual, to the Montgomery standard, not a standard risk list read out for every patient. The gap that matters is generic risk disclosure that ignores what this patient said mattered.

    Strong evidence: The consent record: material risks covered and tied to what mattered to the patient, against the Montgomery v Lanarkshire standard the policy adopts (section 8, procedure step 5, Records and register links).

    Weak evidence: An identical risk list for every patient having that procedure, or the phrase "all material risks discussed" with no risk actually named. The clearest weak spot is a record that captures the patient's job, caring responsibilities or the outcome they said they could not live with earlier in the note, then discusses risk without once connecting back to any of it.

    The recognised standard from a professional or clinical body, such as NICE or a royal college. Not a legal duty, but the accepted mark of safe practice, and a departure needs a documented reason.

  3. Fees are explained in advance, and the record shows the doctor's financial interest in proceeding did not steer the advice, including telling the patient about more conservative options, doing nothing, or care the practice does not provide. The harm shows up as cost arriving as a surprise, or a patient pushed toward a paid procedure.

    Strong evidence: The record: fee information given, and the audit that fees were explained in advance and conflicts of interest managed (sections 9 to 10, procedure step 7, Records and register links, Audit cadence).

    Weak evidence: A price list on the website or in the waiting room treated as the fee discussion, with nothing in this patient's record showing cost was put to them before the procedure, or fee agreement captured only on the invoice afterwards. It also looks like a run of records in which the recommended option is always the one the practice provides, with no note that a more conservative option, waiting, or care available elsewhere was fairly offered.

    The recognised standard from a professional or clinical body, such as NICE or a royal college. Not a legal duty, but the accepted mark of safe practice, and a departure needs a documented reason.

  4. An elective irreversible procedure is not booked on the same day as the first consultation unless there is a recorded clinical reason, and the patient is given time to reflect and told they can change their mind. The failure that matters is a same-day irreversible elective procedure with no clinical justification recorded.

    Strong evidence: The record: cooling-off or reflection period and any same-day treatment rationale, checked in the audit that elective procedures had time to reflect and were free from pressure (section 11, procedure step 7, Records and register links, Audit cadence).

    Weak evidence: Consultation and irreversible elective procedure timestamped the same day, with "patient keen to proceed today" or "patient travelled a long way" standing in for a recorded clinical reason. Equally thin: a reflection period promised in the policy but no field anywhere in the record that ever captures one, and no note that the patient was told they could change their mind at any point.

    Our recommended baseline. Not a legal or regulatory requirement, but a sensible standard we suggest where the rules leave the detail to you. Adapt it to your service.

  5. Where capacity is in doubt, capacity is assessed for that specific decision under the Mental Capacity Act 2005 and a best-interests decision is recorded, with an advocate where the patient has no one to represent them. What goes wrong is capacity presumed away, or a best-interests decision made with no record.

    Strong evidence: The record: capacity assessment, communication support, interpreter or advocate involvement, audited to confirm capacity and best-interests records are present where needed (section 12, procedure step 2, Records and register links, Audit cadence).

    Weak evidence: Capacity never mentioned at all in notes that elsewhere describe confusion, dementia, a learning disability or significant communication difficulty, or a single "has capacity" tick made once at registration rather than an assessment for the specific decision being taken. The commonest gap is a consent form signed by a relative, or the words "family agreed", with no record of a registered lasting power of attorney for health and welfare or a court-appointed deputy behind it, and no record of the person's own wishes, feelings and beliefs. Where the person had nobody to represent them, nothing shows independent advocacy was even considered.

    A legal duty. This comes from legislation that applies to your service, so meeting it is not optional. The exact provision is cited beneath the badge.

    Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, reg 11(3), read with Mental Capacity Act 2005 ss.1(2), 2(1), 3 and 4 (and reg 17(2)(c) for the record)

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Last verified 20 July 2026

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Last reviewed 10 June 2026