A. Communication and patient partnership

Poor communication is at the root of most patient complaints. Effective communication is a two-way exchange, which involves not just talking but also listening with care.
You should be alert to patients’ unspoken signals; for example, when a patient’s body language or tone of voice indicates that they may be uneasy, experiencing discomfort, or anxious and vulnerable.
Patients will come to you with different experiences and expectations. You should try to accommodate their wishes as much as you can without compromising the care you can provide. If you cannot accommodate their wishes, you should explain why you are unable to do so.
Be aware that patients will also have particular needs or values in relation to gender, ethnicity, culture, religion, belief, sexual orientation, lifestyle, age, social status, language, physical and mental health and disability. You must be able to respond respectfully and appropriately to these needs.
Your patients should have your full attention and you should allow sufficient time to deal properly with their needs. If you are in sole practice, you should seek to minimise interruptions while you are with a patient.

Trust is an essential part of a clinical relationship and requires effective communication between osteopath and patient.
You must care for your patients and do your best to understand their symptoms and support their health.
You should be sensitive to the specific needs of patients and be able to select and utilise effective forms of communication, which take these into account.
You should share accurate and relevant information with patients, and encourage them to ask questions and to take an active part in decisions about their treatment and care.
The most appropriate treatment for patients will sometimes involve:
1. referring them to another osteopath or other healthcare professional
2. providing advice on self-care
3. not treating them at all.

Before examining or treating a patient you should ensure that they understand:
1. their rights as a patient, including the right to have a chaperone present and to stop the examination or treatment at any time
2. what they can realistically expect from you as an osteopath.
You should discuss care options, encourage patients to ask questions, and deal with these clearly, fully and honestly. You should inform your patients of anticipated benefits as well as any material or significant risks associated with the treatment you are proposing, and confirm their understanding of these. If proposing no treatment, you should explain any potential risks and benefits associated with this.
If you propose to examine or treat a patient who has difficulty communicating or understanding, you should take all reasonable steps to assist them. For example, make use of an appropriate interpreter if the patient communicates in a different language to you. If you are unable to communicate sufficiently with the patient, you should not treat them.

Gaining consent is a fundamental part of your practice and is both an ethical and a legal requirement. If you examine or treat a patient without consent, you may face criminal, civil or GOsC proceedings.
Gaining consent is an ongoing process. You must ensure that patients are able to make decisions at all stages of their treatment and care and continue to give consent.
For consent to be valid, it must be given:
1. voluntarily
2. by an appropriately informed person
3. with the capacity to consent to the intervention in question.

Voluntarily

For consent to be voluntary, the patient must not be under any form of pressure or undue influence to consent to osteopathic care. You must ensure that patients are given the information they need to reach their own decision and give consent.
Situations where you might question whether consent is voluntary might include patients being put under pressure by employers or relatives to accept osteopathic care, or where a patient might otherwise be vulnerable.

By an appropriately informed person

The patient needs to understand the nature, purpose, benefits and material or significant risks to them of the examination or treatment proposed. The patient must then be free to either accept or refuse the proposed examination or treatment. Some patients may need time to reflect on what you have proposed before they give their consent to it.
Where your diagnostic examination and treatment are carried out simultaneously, consent could be obtained by explaining your approach, describing the types of treatment methods you might like to use, setting the parameters within which you will work, and explaining how the patient may indicate that they wish the treatment to stop. If the patient consents to you proceeding on this basis, you may do so. If the patient expresses concern that you are going outside the agreed treatment plan, you must stop the treatment.
Before deciding that consent has been given, you should consider whether patients have been given the information they want or need, and how well they understand the details and implications of what is proposed.
It is particularly important to ensure that your patient understands and consents to the proposed examination or treatment of any intimate area before it is administered. Intimate areas include the groin, pubis, perineum, breast and anus, but this list is not exhaustive, and patients may regard other areas of their body as ‘intimate’. Some patients may not have come prepared for such a procedure and you should offer to conduct this at a subsequent appointment, and offer a chaperone.

Capacity

Capacity, in this context, relates to the ability of an individual to understand, retain and evaluate information and to make and communicate a decision regarding their health needs and treatment options.
You must not assume that a patient lacks capacity solely because of their age, disability, appearance, behaviour, medical condition, beliefs, or because they make a decision with which you disagree. The starting point should always be a presumption of capacity.
The law recognises that some patients – because of illness, mental capacity or age – are not competent to give consent for a particular examination or treatment. This is because they may not be able to absorb or weigh up the information and make an informed decision.
When an adult lacks mental capacity, decisions about their treatment must be taken in their best interests and in accordance with relevant legislation. Further details on the relevant legislation in England and Wales, Northern Ireland, and Scotland are provided in the GOsC guidance documents for each jurisdiction entitled Obtaining Consent.

Treatment of children and young people

Note that in the summary below a ‘child’ is a person under the age of 16 years and a ‘young person’ is a person aged 16 or 17 years.

Obtaining consent for treatment to be given to a child or young person is a complex issue. If you treat children, you must be aware of the law in this respect, which may vary depending on where you practise in the UK. Further details are provided in the GOsC guidance document Obtaining Consent.
A child may have the capacity to consent. You will need to apply the law, and use your professional judgement in assessing the capacity of each patient under 16 years of age, which will depend on their maturity and ability to understand what is involved. You are strongly advised to involve a person with parental responsibility for the child when seeking consent.
You should involve children and young people as much as possible in discussions about their care, even if they are not able to make decisions on their own.
A young person can be treated as an adult and can be presumed to have the ability to make decisions about their own care. Nevertheless, you will need to use your professional judgement to assess whether the young person in fact has the maturity and ability to understand what is involved in the treatment you are proposing for them because, as with adults, consent must be valid.

Records of consent

You must record key elements of your discussion with the patient. This should include information discussed, any particular concerns, expectations or requests for information raised by the patient, how you addressed these, and any decisions made. It is important that such issues are evidenced in the patient records.
The validity of consent does not depend on the form in which it is given. Written consent may serve as evidence of consent, but if the elements of voluntariness, appropriate information and capacity have not been satisfied, a signature on a form will not by itself make the consent valid.
Valid consent does not always have to be given in writing by the patient. However, if you are proposing a vaginal or rectal examination or technique, written consent must be obtained and kept with the patient records. You may also consider gaining written consent for other procedures, particularly those relating to areas which the patient considers intimate.

Sharing of information

You must obtain specific consent from patients regarding the sharing of any information about them with others.

Supporting patients in caring for themselves may include:

providing information on the effects of their life choices and lifestyle on their health and wellbeing
supporting decision-making about lifestyle changes where appropriate
encouraging and supporting patients to seek help from others, including other health professionals or those coordinating their care, if necessary
respecting patients’ decisions about their care, even if you disagree with those decisions.

Patients will have different requirements for maintaining their dignity and modesty during a consultation, and you must be sensitive to these. Some of these ideas may have been shaped by a patient’s culture or religion, but it is unwise to make assumptions about any patient’s ideas of modesty.
You should respect your patients’ dignity and modesty by:
1. explaining to patients in advance of their first appointment that they may be asked to undress for examination and treatment
2. allowing a patient to undress, and get dressed again, without being observed
3. only observing a patient undressing if you consider this necessary for the purposes of diagnosis or treatment – this must be explained to the patient and consent obtained; if the patient does not wish to be observed, you must respect their wishes and find another way of establishing the clinical information you need
4. giving patients the option of covering areas of their body that do not need to be exposed for examination or treatment. This can be achieved by providing a suitable gown or cover, asking that they only remove such items of clothing as are necessary for the proposed examination or treatment, or providing the opportunity to get dressed again in full or part as appropriate. If you feel it is necessary for the examination or treatment that the patient is undressed to their underwear, you should explain this to the patient, and seek their consent.
If it becomes necessary during examination or treatment to adjust or remove items of the patient’s clothing or underwear, they should be asked to do this themselves. If it is necessary for you to assist them, then you must have their consent to do so.
If you need your patient to remove underwear for an examination or treatment, you should ask them to put their underwear back on at the conclusion of that particular examination or treatment and before you continue with any other procedure.
You must always ask a patient if they would like a chaperone when:
1. you examine or treat an intimate area
2. you are treating a patient under 16 years of age
3. you are treating an adult who lacks capacity
4. you are treating a patient in their home.
A chaperone can be:
1. a relative or friend of the patient
2. a suitable person from your practice but not your spouse or personal partner.
If the patient wishes to have a chaperone and neither you nor the patient is able to provide one, you should offer to rearrange the appointment.
If a chaperone is present, you should record this in the patient records. If a patient within one of the categories in paragraph A6(5) declines the offer of a chaperone, you should record this in the patient’s notes.

The same quality of service and care should be provided to all patients. It is illegal to refuse a service to someone on the grounds of their age, disability, gender reassignment, marriage or civil partnership, pregnancy or maternity, race, religion or belief, sex or sexual orientation.
You should maintain a professional manner at all times, even where a personal incompatibility arises with a patient.
You are not obliged to accept any individual as a patient (subject to the points raised in paragraph 1 above), but if having done so you feel you cannot continue to give them the good-quality care to which they are entitled, you may decline to continue treating them. In that case, you should try to refer them to another osteopath or healthcare professional where appropriate. Reasons for not accepting someone as a patient or declining to continue their care might arise where:
1. they are or become aggressive
2. they seem to lack confidence in the care you are providing
3. they appear to have become inappropriately dependent on you.

A1. You must listen to patients and respect their individuality, concerns and preferences. You must be polite and considerate with patients and treat them with dignity and courtesy.

A2. You must work in partnership with patients, adapting your communication approach to take into account their particular needs and supporting patients in expressing to you what is important to them.

A3. You must give patients the information they want or need to know in a way they can understand.

A4. You must receive valid consent for all aspects of examination and treatment and record this as appropriate.

Voluntarily

By an appropriately informed person

Capacity

Treatment of children and young people

Records of consent

Sharing of information

A5. You must support patients in caring for themselves to improve and maintain their own health and wellbeing.

A6. You must respect your patients’ dignity and modesty.

A7. You must make sure your beliefs and values do not prejudice your patients’ care.