Domain 2: Patients, partnership and communication

'Domain 2: Patients, partnership and communication' is the second domain of Good Surgical Practice, which sets standards for surgeons and members of the surgical team. Good Surgical Practice uses the same headings that appear in Good Medical Practice and is the surgical companion to these General Medical Council (GMC) standards.

About Good Surgical Practice

2.1. Treating patients fairly and respectfully

2.2. Communication with patients

2.3. Remote consultations

2.4. Shared decision making and consent

2.5. Being open when things go wrong

Surgeons must make every effort to establish the trust of their patients and maintain effective relationships with them. They should demonstrate to patients that their safety is paramount and treat them fairly, with courtesy and respect. Clear, open and honest communication is essential for quality of care. Surgeons must allow sufficient time to explain surgical procedures, risks and alternative treatment options. They must understand that seeking informed consent for surgical interventions is a process that requires time, patience and clarity, not merely the signing of a form.

2.1. Treating patients fairly and respectfully

In meeting the requirements of Good Medical Practice, you should:

1. Ensure that you treat patients as individuals and that your conduct is fair, culturally sensitive and non-discriminatory. Be aware of cultural differences and respect them.
2. Respect patients’ right to privacy and confidentiality at all times, particularly when communicating publicly. You should take particular care to protect patients’ confidentiality when using social media.
3. Ensure that decisions about treatment are based on clinical need and the likely effectiveness of treatment and not on lifestyle choices and social, managerial or financial factors that may result in discriminatory access to care.
4. Respect patients’ right to reach their own decisions about their treatment and care, and support patients in caring for themselves to improve and maintain their health.
5. Honour the rights and wishes of a patient in your care, including carefully considering any advance decision (living will) that the patient may have written under the Mental Capacity Act 2005.
6. Ensure that a patient’s dignity is respected at all times; for example, with unconscious patients and in clinical demonstrations.
7. Make sure that the patient understands and is agreeable to the participation of students and other professionals in their care, including outpatient clinics and operative procedures.
8. Gain agreement from the patient if video, photographic or audio records are to be made for purposes other than the patient’s records (eg teaching, research or public transmission).
9. Obtain the patient’s verbal consent before carrying out any physical examination, and support a patient’s request for a chaperone to be present while they are undergoing a physical examination.
10. Explain the purpose and nature of any examination of the breast, genitalia or rectum, and observe GMC guidance on intimate examinations.
11. Support any request for a second opinion and give assistance in making the appropriate arrangements.
12. End the relationship with a patient only when the surgeon–patient relationship has irrevocably broken down and the interests of the patient are best served by ending the current relationship and ensuring an appropriate handover to another doctor for continuing care.

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2.2. Communication with patients

1. Communicate clearly and compassionately with patients and, with the patient’s consent, with their supporters and, in the case of children, with their parents/responsible adults.
2. Listen to and respect patients’ views and preferences and respond to their concerns.
3. Recognise patients’ varying needs for information and explanation and give them the information they want or need using appropriate language in a way that they can understand. Where this is necessary, liaise with your hospital to obtain an independent translator.
4. Ensure that working arrangements allow adequate time to listen and understand patients’ needs and to communicate adequately with them and their supporters. Enough time should also be available for a detailed explanation of the clinical problem and the treatment options. The appropriate clinical manager must be informed if there are inadequacies.
5. Inform patients and their supporters of the plans and procedures of their treatment, the risks and anticipated outcomes and any untoward developments as they occur, or as soon as possible afterwards.

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2.3. Remote consultations

1. Provide effective care whether patient consultations take place face-to-face or remotely, (via telephone or video link). Remote consultations can be used for a wide range of patients and for many follow-up appointments, provided that patients are able and willing to communicate via telephone or video and that they do not need physical examinations or tests.
   
   
2. Surgeons should generally not use remote consultations when:
   1. patients have high-risk conditions that may need a physical examination;
   2. a close visual examination of an area may be appropriate;
   3. an internal examination (eg digital rectal examination) is required;
   4. the patient’s mental state is unsuitable for a virtual consultation (eg dementia);
   5. patients are unable to use remote technology to communicate and they cannot be supported to do so by a carer;
   6. there are safeguarding concerns.
3. For patients with disability or sensory loss, consider whether their needs can be met through a virtual consultation (eg by using assistive technology and software developed for people with sensory impairments).

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2.4. Shared decision making and consent

Surgeons should recognise that seeking consent for surgical interventions is not merely the signing of a form. It is the process of providing the information that enables the patient to make a decision to undergo a specific treatment. Consent should be considered informed decision making, or informed request. It requires time, patience and clarity of explanation.

In meeting the requirements of Good Medical Practice, you should:

1. Give the patient the information they need to make an informed decision about treatment. It may be appropriate, in order to facilitate discussion, to send information to the patient in advance. In practice, this means that surgeons should provide information about:
   
   1. the patient’s diagnosis and prognosis;
   2. the right of the patient to refuse treatment and make their own decisions about their care;
   3. options for treatment, including non-operative care and no treatment;
   4. advice on lifestyle that may moderate the disease process;
   5. the purpose and expected benefit of the treatment;
   6. the nature of the treatment (what it involves);
   7. the risks inherent in the procedure, however small the possibility of their occurrence, side effects and complications;
   8. the likelihood of success;
   9. the clinicians involved in their treatment;
   10. potential follow-up treatment;
   11. for private patients, costs of treatment and potential future costs in the event of complications.
2.  Make patients aware of national guidelines on treatment choices, such as NICE and Scottish Intercollegiate Guidelines Network guidelines. If your recommended treatment is not in keeping with current guidelines, you must explain your reason for not following current standard guidelines.
3. Ensure that the discussion is tailored to the individual patient. This requires time to get to know the patient well enough to understand their views and values. Recognise that the patient may not have the same values, wishes or life priorities as you would have in a similar situation. You should therefore not make assumptions regarding what they might perceive as the best option available.
4. Ensure that consent is obtained either by the person who is providing the treatment or by someone who is suitably trained and qualified to provide the treatment in question and has sufficient knowledge of the associated risks and complications, as well as any alternative treatments available for the patient’s condition.
5. Obtain the patient’s consent prior to surgery and ensure that the patient has sufficient time for reflection and sufficient information to make an informed decision. A patient’s consent should not be taken in the anaesthetic room. The duration of the discussion and the length of the reflection period will vary based on the complexity and risks of the proposed procedure. In the case of cosmetic surgery, the required reflection period should be at least two weeks between the consent discussion and the cosmetic intervention.
6. Where possible, provide written information to patients to enable them to reflect on and confirm their decision. You should also provide advice on how they can obtain further information to understand the procedure and their condition. This can include information such as patient leaflets, decision aids, websites and educational videos.
7. Sign the consent form at the end of the consent discussion, allowing the patient to take a copy for reference and reflection. On the day of the procedure, check with the patient whether anything has changed since the consent discussion. If there has been a significant delay since the original signing, sign the relevant section on the form to confirm consent. The patient does not need to sign again.
8. In addition to the consent form, maintain a record of the discussion (including contemporaneous documentation of the key points of the discussion, hard copies or web links of any further information provided to the patient, and the patient’s decision) and include it in the patient’s case notes. This is important even if the patient chooses not to undergo treatment.

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2.5. Being open when things go wrong

Surgeons must be open and honest with patients if things go wrong. According to Good Medical Practice 2024 (para. 45), if a patient under your care has suffered harm or distress, you should put matters right (if that is possible), offer an apology, and explain what has happened and the likely short-term and long-term effects.

According to surgical guidance on the Duty of Candour (Royal College of Surgeons of England, 2017), identifying such an incident does not automatically imply error, negligence or poor-quality care. It simply indicates that an unexpected and undesirable clinical outcome resulted from some aspect of the patient’s care, rather than the patient's underlying condition.

Similarly, apology does not imply acceptance of responsibility for the incident and the resulting harm. It is an expression of sorrow or regret in relation to an unexpected incident.

In cases, however, where harm is linked to an error, then an apology should also include an acknowledgement and acceptance of responsibility – this is not an admission of legal liability.

Specifically, you should:

1. Inform patients promptly and openly of any significant harm that occurs during their care, whether or not the information has been requested and whether or not a complaint has been made.
2. Act immediately when patients have suffered harm, promptly apologise and, where appropriate, offer reassurance that similar incidents will not reoccur.
3. Report all incidents where significant harm has occurred through the relevant governance processes of your organisation.
4. Treat complaints with courtesy and respect and respond promptly, openly and honestly, acknowledging harm and offering redress where appropriate.
5. Cooperate with local complaints procedures. If you consider that a complaint is unjustified or vexatious, you should refer it to the medical director or an appointed arbitrator for independent review.
6. Participate fully in any investigations relating to significant harm, following local guidelines. If you appear to the coroner’s court, you must provide prompt and complete evidence including comprehensive and truthful reports.

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