Equality and Diversity Policy

Bretton Park Healthcare operates an Equality and Diversity Policy as follows:

The term ‘visitor’ used below refers to anyone (including patients and their family members, other visitors and contractors) making use of the Practice’s premises and services.

The Practice:

  • will ensure that all visitors are treated with dignity and respect
  • will promote equality of opportunity between men and women 
  •  will not tolerate any discrimination against, or harassment of, any visitor for reason of age, sex, marital status, pregnancy, race, ethnicity, disability, sexual orientation, religion or belief
  • will provide the same treatment and services (including the ability to register with the Practice) to any visitor irrespective of age, sex, marital status, pregnancy, race, ethnicity, disability, sexual orientation, religion or belief


This Policy applies to the general public, including all patients and their families, visitors and contractors.


Discrimination by the Practice against you:
If you feel discriminated against:

  • You should bring the matter to the attention of the Practice Manager.
  • The Practice Manager will investigate the matter thoroughly and confidentially within 14 working days.
  • The Practice Manager will establish the facts, and decide whether discrimination has taken place and advise you of the outcome of the investigation within 10 working days. 

If you are not satisfied with the outcome, you should raise a formal complaint through the Practice’s Complaints Procedure

Discrimination against the Practice’s staff:

Bretton Park Healthcare will not tolerate any form of discrimination or harassment of our staff by any visitor. Any visitor, who expresses any form of discrimination against, or harassment of, any member of our staff, will be required to leave the Practice’s premises forthwith. If the visitor is a patient, he/she may be removed from the Practice’s list if any such behaviour occurs on more than one occasion. 

Consent Policy

General Consent

When Do Health Professionals Need Consent From Patients?

Before you examine, treat or care for competent adult patients you must obtain their consent.

Adults are always assumed to be competent unless demonstrated otherwise. If you have doubts about their competence, the question to ask is: “Can this patient understand and weigh up the information needed to make this decision?” Unexpected decisions do not prove the patient is incompetent, but may indicate a need for further information or explanation.

Patients may be competent to make some health care decisions, even if they are not competent to make others.

Giving and obtaining consent is usually a process, not a one-off event.

Patients can change their minds and withdraw consent at any time. If there is any doubt, you should always check that the patient still consents to your caring for or treating them.

Can Children Give Consent For Themselves?

Before examining, treating or caring for a child, you must also seek consent.

Young people aged 16 and 17 are presumed to have the competence to give consent for themselves.

Younger children who understand fully what is involved in the proposed procedure can also give consent (although their parents will ideally be involved). In other cases, some-one with parental responsibility must give consent on the child’s behalf, unless they cannot be reached in an emergency. If a competent child consents to treatment, a parent cannot over-ride that consent. Legally, a parent can consent if a competent child refuses, but it is likely that taking such a serious step will be rare.

Who is the right person to seek consent?

It is always best for the person actually treating the patient to seek the patient’s consent. However, you may seek consent on behalf of colleagues if you are capable of performing the procedure in question, or if you have been specially trained to seek consent for that procedure.

What information should be provided?

Patients need sufficient information before they can decide whether to give their consent: for example information about the benefits and risks of the proposed treatment, and alternative treatments. If the patient is not offered as much information as they reasonably need to make their decision, and in a form they can understand, their consent may not be valid.

Consent must be given voluntarily: not under any form of duress or undue influence from health professionals, family or friends.

Does It Matter How The Patient Gives Consent?

• No: consent can be written, oral or non-verbal. A signature on a consent form does not itself prove the consent is valid – the point of the form is to record the patient’s decision, and also increasingly the discussions that have taken place.

Refusal of Treatment

• Competent adult patients are entitled to refuse treatment, even when it would clearly benefit their health. The only exception to this rule is where the treatment is for a mental disorder and the patient is detained under the Mental Health Act 2007 in which case the patient can receive care or treatment relating to his mental health disorder/illness without giving consent. However, in this situation the patient still retains the right to give or refuse consent for any other care or treatment should he/she be deemed competent to do so. A competent pregnant woman may refuse any treatment, even if this would be detrimental to the foetus.

Adults Who Are Not Competent To Give Consent

• No-one can give consent on behalf of an incompetent adult. However, you may still treat such a patient if the treatment would be in their best interests ‘Best interests’ go wider than best medical interests, to include factors such as the wishes and beliefs of the patient when competent, their current wishes, their general well-being and their spiritual and religious welfare. People close to the patient may be able to give you information on some of these factors. Where the patient has never been competent, relatives, carers and friends may be best placed to advise on the patient’s needs and preferences.

• If an incompetent patient has clearly indicated in the past, while competent, that they would refuse treatment in certain circumstances (an ‘advance refusal’), and those circumstances arise, you must abide by that refusal. Any ‘advance refusal’ regarding life sustaining treatment in a life threatening situation must be witnessed and signed by the patient and the witness.

Types of Consent

Consent is often wrongly equated with a patient’s signature on a consent form. A signature on a form is evidence that the patient has given consent, but is not proof of valid consent. If a patient is rushed into signing a form, on the basis of too little information, the consent may not be valid, despite the signature. Patients may, if they wish, withdraw consent after they have signed a form: the signature is evidence of the process of consent-giving, not a binding contract.

If a patient has given valid verbal consent, the fact that they are physically unable to sign the form is no bar to treatment.

Implied Consent

The majority of examinations provided by health professionals are carried out under implied consent This is no longer considered best practice as staff should not rely on a patient’s apparent compliance with a procedure as a form of consent i.e. the fact that a patient lies down on an examination couch does not in itself indicate that the patient has understood what is proposed and why. For consent to be legal, the professional must demonstrate through documentation that the patient understands the process, procedure, problems and outcome. If there is an alternative to this procedure, this must also be fully discussed.

Verbal Consent

Verbal consent should be sought before any procedure takes place. A clear explanation of what is to be done, any risks to consider and any alternative should be discussed with the patient. The discussion which takes place should be recorded in the case notes. Written evidence of consent should include how you tested that the patient understood what was going to be done to them; this will demonstrate that informed consent was given. As with all entries to case notes, the date and time must be recorded and the entry signed.

Written Consent

There are no legal requirements in terms of specific procedures that require written consent. However, as a matter of good practice, the General Medical Council guidance states that written consent should be obtained in cases where the treatment is complex, or involves significant risks and /or side effects (the term ‘risk’ is used throughout to refer to any adverse outcome, including those which some health professionals would describe as ‘side-effects’ or complications’)

The guidance on best practice applies especially to:

• Minor surgery performed under local anaesthesia.

• the provision of clinical care is not the primary purpose of the investigation or examination eg videoing of consultation for education and training

• there may be significant consequences for the patient’s employment, social or personal life.

• the treatment is part of research programme

Mental Capacity Act 2006

The Mental Capacity Act 2005 (the Act) provides the legal framework for acting and making decisions on behalf of individuals who lack the mental capacity to make particular decisions for them. Everyone working with and/or caring for an adult who may lack capacity to make specific decisions must comply with this Act when making decisions or acting for that person, when the person lacks the capacity to make a particular decision for themselves. The same rules apply whether the decisions are life-changing events or everyday matters.

For mental capacity principles, assessments, best interests, restraint & deprivation of liberty information please refer to Policy for Mental Capacity Procedures to follow when patients lack capacity to give or withhold consent

Where an adult patient does not have the capacity to give or withhold consent to a significant intervention, this fact should be documented in form 4 (form for adults who are unable to consent to investigation or treatment), along with the assessment of the patient’s capacity, why the health professional believes the treatment to be in the patient’s best interests, and the involvement of people close to the patient. The standard consent forms should never be used for adult patients unable to consent for themselves. For more minor interventions, this information should be entered in the patient’s notes.

The Mental Capacity Act introduced a duty on NHS bodies to instruct an independent mental capacity advocate (IMCA) in serious medical treatment decisions when a person who lacks the capacity to make a decision has no one who can speak for them, other than paid staff. The Act allows people to plan ahead for a time when they may not have the capacity to make their own decisions: it allows them to appoint a personal welfare attorney to make health and social care decisions, including medical treatment, on their behalf or to make an advance decision to refuse medical treatment. Further guidance is available in the Mental Capacity Act (2005) Code of Practice.

An apparent lack of capacity to give or withhold consent may in fact be the result of communication difficulties rather than genuine incapacity. You should involve appropriate colleagues in making such assessments of incapacity, such as specialist learning disability teams and speech and language therapists, unless the urgency of the patient’s situation prevents this. If at all possible, the patient should be assisted to make and communicate their own decision, for example by providing information in non-verbal ways where appropriate.

Occasionally, there will not be a consensus on whether a particular treatment is in an incapacitated adult’s best interests. Where the consequences of having, or not having, the treatments are potentially serious, a court declaration may be sought.

Is The Consent Given Voluntarily?

To be valid, consent must be given voluntarily and freely, without pressure or undue influence being exerted on the person either to accept or refuse treatment. Such pressure can come from partners or family members, as well as health or care practitioners. Practitioners should be alert to this possibility and where appropriate should arrange to see the person on their own in order to establish that the decision is truly their own.

When people are seen and treated in environments where involuntary detention may be an issue, such as prisons and mental hospitals, there is a potential for treatment offers to be perceived coercively, whether or not this is the case. Coercion invalidates consent, and care must be taken to ensure that the person makes decisions freely. Coercion should be distinguished from providing the person with appropriate reassurance concerning their treatment, or pointing out the potential benefits of treatment for the person’s health. However, threats such as withdrawal of any privileges, loss of remission of sentence for refusing consent or using such matters to induce consent may well invalidate the consent given, and are not acceptable.

Written Consent

Consent is often wrongly equated with a patient’s signature on a consent form. A signature on a form is evidence that the patient has given consent, but is not proof of valid consent. If a patient is rushed into signing a form, on the basis of too little information, the consent may not be valid, despite the signature. Similarly, if a patient has given valid verbal consent, the fact that they are physically unable to sign the form is no bar to treatment. Patients may, if they wish, withdraw consent after they have signed a form: the signature is evidence of the process of consent-giving, not a binding contract.

It is good practice to get written consent if any of the following circumstances apply:

•  the treatment or procedure is complex, or involves significant risks (the term ‘risk’ is used throughout to refer to any adverse outcome, including those which some health professionals would describe as ‘side-effects’ or ‘complications’)

•  the procedure involves general/regional anaesthesia or sedation

• providing clinical care is not the primary purpose of the procedure

• there may be significant consequences for the patient’s employment, social or personal life

• the treatment is part of a project or programme of research

Completed consent forms should be scanned onto the patient’s EMIS notes. Any changes to a consent form, made after the form has been signed by the patient, should be clearly documented.

It will not usually be necessary to document a patient’s consent to routine and low risk procedures, such as providing personal care or taking a blood sample.

However, if you have any reason to believe that the consent may be disputed later or if the procedure is of particular concern to the patient (for example if they have declined, or become very distressed about, similar care in the past) it would be helpful to do so.

Treatment of Young Children

Parental responsibility: The mother of a child, and the child’s father (if he is married to the mother) automatically have parental responsibility. If the parents are not married, the father will have parental responsibility if he acted with the mother to have his name recorded in the registration of the child’s birth and the child’s birth was registered after 1 December 2003.

An unmarried father can also obtain parental responsibility by later marrying the mother, by making a parental responsibility agreement with her, or by getting a court order. Parental responsibility can also be granted to other people by the courts, such as a legally appointed guardian. Members of Staff are advised to check carefully and record details of parental responsibility in the child’s records. Parents and those with parental responsibility can only provide or refuse consent if they are thought to be capable and can communicate their decision. Children who are under 16 years of age can also consent or refuse treatment if it is thought that they have sufficient intelligence, competence, and understanding to fully appreciate what is involved in their treatment. This was recognised in the House of Lords in the Fraser case of 1986 which resulted in the concept of ‘Fraser Competent’ :-Refer to Fraser Guidelines (1986)

Teenagers and Consent & Confidentiality

Teenagers who are 16 or 17 years of age are entitled to consent to their own treatment.

Who Is Responsible For Seeking Consent?

The health professional carrying out the procedure is ultimately responsible for ensuring that the patient is genuinely consenting to what is being done: it is they who will be held responsible in law if this is challenged later.

Where oral or non-verbal consent is being sought at the point the procedure will be carried out, this must be done by the health professional responsible.

For more information please see: https://www.nhs.uk/conditions/consent-to-treatment/

Chaperone Policy

Table of contents

1          Introduction    1

1.1       Policy statement         1

1.2       Status  2

2          Policy   2

2.1       Raising patient awareness      2

2.2       Personnel authorised to act as chaperones   2

2.3       General guidance        2

2.4       Expectations of a chaperone  3

2.5       Disclosure and Barring Service (DBS) check   4

2.6       When a patient refuses a chaperone 4

2.7       When a chaperone is unavailable  4

2.8       Using chaperones during a video consultation  4

2.9       Practice procedure  5

2.10     Escorting of visitors and guests (including VIPs)   5

3   Summary  6

1 Introduction

1.1 Policy statement

At Bretton Park Healthcare, all patients will routinely be offered a chaperone, ideally at the time of booking their appointment. It is a requirement that, where necessary, chaperones are provided to protect and safeguard both patients and clinicians during intimate examinations and or procedures.

All clinical staff may at some point be asked to act as a chaperone at Bretton Park Healthcare. Therefore, it is essential that clinical personnel are fully trained and aware of their individual responsibilities when performing chaperone duties.

The importance of a chaperone should not be underestimated. Children and young people, their parents, relatives and carers should be made aware of the policy and why this is important.

1.2 Status

The organisation aims to design and implement policies and procedures that meet the diverse needs of our service and workforce, ensuring that none are placed at a disadvantage over others, in accordance with the Equality Act 2010. Consideration has been given to the impact this policy might have with regard to the individual protected characteristics of those to whom it applies.

This document and any procedures contained within it are non-contractual and may be modified or withdrawn at any time. For the avoidance of doubt, it does not form part of your contract of employment.

2 Policy

2.1  Raising patient awareness

Patients are to be advised that a chaperone is ‘an independent person, appropriately trained, whose role is to observe independently the examination/procedure undertaken by the doctor/health professional to assist the appropriate doctor-patient relationship’.

At Bretton Park Healthcare, a chaperone poster is clearly displayed in the waiting area, in all clinical areas as well as on the organisation website.

2.2  Personnel authorised to act as chaperones

It is policy that any member of the organisation team can act as a chaperone only if they have undertaken appropriate chaperone training. The GMC advises that a relative or friend of the patient is not considered to be an impartial observer and therefore would not be considered a suitable chaperone.

2.3 General guidance

All clinicians should consider using a chaperone for some or all of the consultation and not solely for the purpose of intimate examinations or procedures. This applies whether the clinician is of the same gender as the patient or not.

Before conducting any intimate examination, the clinician should follow this checklist:

  • Explain to the patient why the particular examination is necessary and what it entails so they can give fully informed consent
  • Record the consent discussion in the notes, along with the identity of the chaperone or if a chaperone was offered but declined
  • If possible, use a chaperone of the same gender as the patient
  • Allow the chaperone to hear the explanation of the examination and the patient’s consent

During the examination, the clinician should:

  • Ensure the patient’s privacy during the examination when they are dressing and undressing, for example by using screens and gowns/sheets
  • Position the chaperone where they can see the patient and how the examination is being conducted
  • Explain what they are going to do before they do it and seek consent again (if the examination is going to differ from what the patient was previously advised)
  • Avoid personal remarks
  • Invite the patient to advise if the examination becomes uncomfortable.
  • Watch the patient for any signs of pain or discomfort and check the patient is happy for the examination to continue

Ensuring that the patient fully understands the why, what and how of the examination process should mitigate the potential for confusion.

2.4 Expectations of a chaperone

All staff who undertake a formal chaperone role must have been trained so they develop the competencies required. Training can be delivered externally or provided in-house by an experienced member of staff so that all formal chaperones understand the competencies required for this role.1

At Bretton Park Healthcare, chaperone training will include:

  • What is meant by the term chaperone
  • What an intimate examination is
  • Why chaperones need to be present
  • The rights of the patient
  • The role and responsibilities of the chaperone. Chaperones must place themselves inside the screened off area rather than outside of the curtains/screen
  • The policy and mechanism for raising concerns

Training will be provided in-house by a suitably qualified individual or externally from an accredited source. The practice training coordinator will provide information on this training.

Additionally, at Bretton Park Healthcare chaperones will adhere to the GMC guidance which states chaperones should:

  • Be sensitive and respect the patient’s dignity and confidentiality
  • Reassure the patient if they show signs of distress or discomfort
  • Be familiar with the procedures involved in a routine intimate examination
  • Stay for the whole examination and be able to see what the doctor is doing, if practical
  • Be prepared to raise concerns if they are concerned about the doctor’s behaviour or actions

For most patients and procedures, respect, explanation, consent and privacy are all that is needed. These take precedence over the need for a chaperone. A chaperone does not remove the need for adequate explanation and courtesy. Neither can a chaperone provide full assurance that the procedure or examination is conducted appropriately.1

2.5 Disclosure and Barring Service (DBS) check

Clinical staff who undertake a chaperone role at Bretton Park Healthcare will already have a DBS check. Non-clinical staff who carry out chaperone duties may need a DBS check. This is due to the nature of chaperoning duties and the level of patient contact. Should Bretton Park Healthcare decide not to carry out a DBS check for any non-clinical staff, then a clear rationale for this decision must be given, including an appropriate risk assessment.

2.6 When a patient refuses a chaperone

When a patient is offered but does not want a chaperone, it is important the organisation has records and codes in the record:

  • Who the chaperone was
  • Their title
  • That the offer was made and declined

2.7 When a chaperone is unavailable

If the patient has requested a chaperone and none is available, the patient must be able to reschedule within a reasonable timeframe. If the seriousness of the condition means a delay is inappropriate, this should be explained to the patient and recorded in their notes. A decision to continue or not should be reached jointly. Special consideration needs to be given to examinations performed during home visits or online, video or telephone consultations.1

2.8 Using chaperones during a video consultation

Many intimate examinations will not be suitable for a video consultation. When online, video or telephone consultations take place, GMC guidance explains how to protect patients when images are needed to support clinical decision making. This includes the appropriate use of photographs and video consultations as part of patient care.

Where intimate examinations are performed, it is important that a chaperone is offered. Documentation should clearly reflect this. It is important to document who provided the chaperoning and this should also state what part of the consultation they were present for.

This guidance explains how to conduct intimate examinations by video and the use of chaperones.

2.9 Practice procedure

If a chaperone was not requested at the time of booking the appointment, the clinician will offer the patient a chaperone explaining the requirements:

  • Contact reception and request a chaperone
  • Record in the individual’s healthcare record that a chaperone is present and identify them
  • The chaperone should be introduced to the patient
  • The chaperone should assist as required but maintain a position so that they are able to witness the procedure/examination (usually at the head end)
  • The chaperone should adhere to their role at all times
  • Post procedure or examination, the chaperone should ensure they annotate in the patient’s healthcare record that they were present during the examination and there were no issues observed
  • The clinician will annotate in the individual’s healthcare record the full details of the procedure as per current medical records policy

2.10     Escorting of visitors and guests (including VIPs)

There may be, on occasion, a need to ensure that appropriate measures are in place to escort visitors and guests including Very Important People (VIPs).

Bretton Park Healthcare will follow the recommendations outlined in the Lampard Report (2015) :

  1. Ensure that any visitors are escorted by a permanent member of staff at all times throughout the duration of their visit
  2. The individual organising the visit must arrange for a suitable member of staff to act as an escort. Furthermore, the reason for the visit must be documented, giving details of the areas to be visited and if patients are to be contacted during the visit
  3. The escort is to ensure that no visitors enter clinical areas where there may be intimate examinations or procedures taking place. This protects and promotes the privacy, dignity and respect of patients
  4. The person arranging the visit must ensure that there is sufficient time for the practice team to advise patients of the visit and offer patients the opportunity to decline to interact with the visitor(s)
  5. Given the diverse nature of the patient population, some patients may not understand or may become confused as to why visitors or guests (including VIPs) are present. To minimise any confusion or distress, such patients as well as the visitor(s) are to be offered an escort
  6. The person arranging the visit must ensure that the visitor(s) has produced photographic ID prior to the visit taking place
  7. The escort is to accept responsibility for the visitor(s) at all times. They must also be prepared to challenge any unacceptable or inappropriate behaviour, reporting such incidences to the practice manager immediately
  8. The escort must ensure that no patient records or other patient-identifiable information are disclosed to the visitor(s). Escorts are to ensure that the visitor(s) is aware of the need to retain confidentiality should they overhear clinical information being discussed. Any breaches of confidentiality are to be reported immediately to the practice manager
  9. If media interest is likely, the practice manager is to inform Cambridgeshire and Peterborough ICB, requesting that the communication team provides guidance
  10. Under no circumstances is the escort to leave the visitor(s) alone with any patient or patient-identifiable information. This is to ensure that both the patient and visitor(s) are appropriately protected

3 . Summary

The relationship between the clinician and patient is based on trust and chaperones are a safeguard for both parties at Bretton Park Healthcare.

The role of a chaperone is vital in maintaining a good standard of practice during consultations and examinations. Regular training for staff and raising patient awareness will ensure that this policy is maintained.

Zero Tolerance Policy

The Practice takes it very seriously if a member of staff or one of the doctors or nursing team is treated in an abusive or violent way.

The Practice supports the government’s ‘Zero Tolerance’ campaign for Health Service Staff. This states that GPs and their staff have a right to care for others without fear of being attacked or abused. To successfully provide these services a mutual respect between all the staff and patients has to be in place. All our staff aim to be polite, helpful, and sensitive to all patients’ individual needs and circumstances. They would respectfully remind patients that very often staff could be confronted with a multitude of varying and sometimes difficult tasks and situations, all at the same time.  The staff understand that ill patients do not always act in a reasonable manner and will take this into consideration when trying to deal with a misunderstanding or complaint.

However, aggressive behaviour, be it violent or abusive, will not be tolerated and may result in you being removed from the Practice list and, in extreme cases, the Police being contacted.

In order for the practice to maintain good relations with their patients the practice would like to ask all its patients to read and take note of the occasional types of behaviour that would be found unacceptable:

  • Using bad language or swearing at practice staff
  • Any physical violence towards any member of the Primary Health Care Team or other patients, such as pushing or shoving
  • Verbal abuse towards the staff in any form including verbally insulting the staff
  • Racial abuse and sexual harassment will not be tolerated within this practice
  • Persistent or unrealistic demands that cause stress to staff will not be accepted. Requests will be met wherever possible and explanations given when they cannot
  • Causing damage/stealing from the Practice’s premises, staff or patients
  • Obtaining drugs and/or medical services fraudulently

We ask you to treat your GPs and their staff courteously at all times.

Removal from the practice list

The removal of patients from our list is an exceptional and rare event and is a last resort in an impaired patient-practice relationship. We value and respect good patient-doctor relationships based on mutual respect and trust. When trust has irretrievably broken down, the practice will consider all factors before removing a patient from their list, and communicate to them that it is in the patient’s best interest that they should find a new practice. An exception to this is in the case of immediate removal on the grounds of violence e.g. when the Police are involved.

Removing other members of the household

In rare cases, however, because of the possible need to visit patients at home it may be necessary to terminate responsibility for other members of the family or the entire household. The prospect of visiting patients where a relative who is no longer a patient of the practice by virtue of their unacceptable behaviour resides, or being regularly confronted by the removed patient, may make it too difficult for the practice to continue to look after the whole family. This is particularly likely where the patient has been removed because of violence or threatening behaviour and keeping the other family members could put doctors or their staff at risk.

Zero Tolerance