This article relates to the CQC key question: Is your practice effective?
It is a general principle that valid consent must be obtained before starting treatment, a physical examination or a physiological test or investigation.
This reflects people’s right to determine what happens to their bodies, and is a fundamental part of good general practice. As part of CQC’s assessment of how effective a practice is, our inspectors will always seek evidence that people’s consent to care and treatment are sought in line with legislation and guidance.
Obtaining consent for minor surgery
The principles of informed consent are particularly important for interventions with risks and side effects. Minor surgery carried out in general practice includes a wide range of procedures from joint and soft tissue injections to complex procedures involving excisions.
In the case of relatively minor procedures, for example joint injections, consent can be recorded in the patient’s records. In the case of more invasive procedures, for example excisions, written consent should be obtained.
What do case notes need to contain?
However, obtaining written consent is not in and of itself enough. It can serve as a checklist to ensure necessary elements are covered and is a record that consent was sought. The consent is valid if it is given voluntarily and appropriate information and capacity have been satisfied. Key elements of the discussion with the patient should be recorded in the case notes, including:
- Information discussed
- Any specific requests by the patient
- Any written, visual or audio information given to the patient
- Details of any decisions that were made
The General Medical Council guidance to individual practitioners Consent: patients and doctors making decisions together (2008) can be accessed via their website.
Registration with CQC: Regulated activity surgical procedures and joint injections
GP practices are required to register with CQC for certain regulated activities. We often get asked whether GP practices are required to register for the regulated activity of ‘surgical procedures’ if they are carrying out joint injections: joint injections are covered in the regulated activity of treatment of disease, disorder and injury and do not fall within the scope of the surgical procedures regulated activity.
The regulated activity of surgical procedures does not include minor surgical procedures if they are:
- Undertaken by a medical practitioner
- Limited to curettage, cautery or cryocautery of warts, verrucae or other skin lesions
- Carried out using local anaesthesia, or no anaesthesia
Practices are not required to register for the surgical procedures regulated activity if they are providing these minor surgical procedures.
Always refer to our guidance The scope of registration when considering what regulated activities to register for.
- Professor Nigel Sparrow is senior national GP advisor and responsible officer at the CQC
More CQC resources
- View the full CQC Essentials series on Medeconomics
- CQC's recommended reading to help practices meet regulations and prepare for an inspection