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President’s Bulletin: Consent – make sure you are familiar with GMC Guidance

Updated on: 03 Dec 2021   First published on 30 Nov 2021

Authors:  Dr Alastair McKinlay   Prof Andy Veitch   Dr Bernard Brett   Dr Ian Penman 

Informed consent underpins all of our clinical activity.

This blog is important and concerns consent for procedures.

Earlier this year, the BSG received a letter from the General Medical Council detailing an enquiry that they had received, which concerned consent for endoscopic procedures. In particular, the GMC was interested in issues around postal consent and whether patients had sufficient opportunity to discuss a procedure before it was carried out.

The BSG consent guideline was published in 2016 under the expert chairmanship of Dr. Simon Everett. The working group included representation from the medical defence societies and expert legal opinion. It was written in the light of the Montgomery ruling, the legal benchmark for issues of consent.

In our guideline, the BSG moved away from recommending postal consent and instead emphasised the importance of the patient receiving relevant information before arriving for their procedure.

The BSG responded positively to the comments from the GMC and in addition to correspondence over the summer, we had a very useful direct conversation with the Standards and Ethics division last week.

We believe that the principles laid out in the BSG guidelines still apply, but must be read in conjunction with updated GMC guidance on consent.

Under Montgomery, it is the patient who decides whether they have been properly informed to enable them to determine what level of risk they are prepared to accept, and whether there are any suitable alternatives and the clinician must assist them in that process by providing sufficiently detailed information. Patients must receive a balanced view of the risks and benefits, including those for alternative procedures (including doing nothing) at a level that they understood, which they believe fully answers their questions and meets their requirements, whilst accepting that individuals will have different preferences for detail. It remains the duty of the endoscopist to assess whether the patient has given informed consent before performing any procedure. If there is any suggestion that a patient with capacity is not satisfied, or feels unable to give informed consent, then the procedure should not take place. Every effort should be made to provide the patient with any additional information, guidance, or advice that they might need to inform their decision, whilst respecting their absolute right to decline any procedure or treatment that they do not wish to undergo, even if this is contrary to medical advice.

For most patients, particularly for lower-risk procedures, a well worded, easy to read information leaflet will provide sufficient information for their needs. We must however not make the assumption this is the case and the endoscopist should check that the patient is satisfied they have received sufficient information.

The GMC stressed the importance of proportionality in the consent process. High-risk procedures such as ERCP and PEG insertion require a detailed discussion with the patient or their representatives. The indications for some procedures may be better discussed in a multidisciplinary context.

Units should review their practice and in particular any information or advice leaflets that they give to patients. In some circumstances, a pre-assessment process with suitably trained staff may be helpful.

The GMC was clear that it did not seek to impose requirements on us as a Society, nor did they wish to either undermine or “sign off” on guidelines. We, however, felt that it would be useful to review our guideline, to ensure that it remains in line with the GMC’s own more recent publications. In the meantime, it would be prudent for our members to make sure they are familiar with the most recent GMC guidance. A link to this will also be placed alongside our guidelines on the Society’s website.

We have also agreed to commission a plain English version of any revised guidance designed for patients seeking more information. It is now our intention to have a patient information leaflet and summary for all our new guidelines, similar to that produced by the working party on anticoagulation and endoscopic procedures, chaired by the President-Elect Dr. Andy Veitch.

The meeting with the GMC was very positive and I think we clarified many of the issues around safe practice and consent for endoscopy.

Finally, quality improvement initiatives such as JAG accreditation and the implementation of the GIRFT recommendations not only improve patient care, but also are the best way of protecting the reputation of individuals and their units, and we strongly commend them.

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