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Editor,—The personal practice article by Chambers and Panting provided helpful information about the consent issues that surround the examination of young children.1 However, it failed to touch on the specific problems encountered by those working in the school health service, who may find themselves examining unaccompanied children.
In April 1994, Salford Community Healthcare Trust received a complaint about the school entry medical examination of a 4 year old boy that had included examination of the child’s genitalia. The parents had been sent a covering letter explaining that the child would have a full medical examination, and had signed and returned the consent form stating that they would not attend the medical. Following their complaint, the doctor concerned was suspended until the social services department had completed inquiries into the implied allegation of sexual abuse. The complaints procedure dragged on until December 1995, when external adjudicators vindicated the doctor and commented that the trust’s paperwork relating to school entrant medical examinations was as good as that in many other districts.
The complaint led to a review of consent arrangements for all school health activity. Previously, vision checks, dental inspections, nursing activity and so on, had been carried out with implied consent if parents did not raise objections to a notification that their child was to be seen. The trust sought legal advice and it was suggested that express consent should be obtained for each and every contact with a member of the school health team. This would have imposed an enormous clerical workload and a pilot study resulted in only 60% of children being seen. The compromise has been to obtain signed consent annually for all mainstream primary children for the core programme of school health activity.
Medical examinations, immunisatons, and contacts with children outside the core programme, still require express consent. Mainstream secondary school pupils are asked to give their own consent to meeting the school nurse for health reviews and for making use of drop-in sessions.
Initial reaction to the new arrangements was hostile. Many councillors, head teachers, and school governors felt that the arrangements were unnecessarily bureaucratic and that school health services were effectively being withdrawn from those who most needed them. The local education committee threatened judicial review, but then sought counsel’s opinion in conjunction with the health authority, and informed the trust that it was ‘not acting illegally’ by insisting on signed consent. These fears have been largely unfounded; overall 93% of consent forms have been returned, with a number of schools including some in the most deprived wards achieving 100% return rates.
Little practical guidance about consent is available to school health staff. The Department of Health document, Child Health in the Community: A Guide to Good Practice issued in September 1996 notes that ‘the Department regularly receives complaints from parents who claim they were not given prior notice of an examination by the school health service’. It suggests that consent can be obtained at school entry for ‘the range of developmental checks and immunisations on offer’ and that parents are informed when a medical check or immunisation is planned. It also suggests that others such as therapists should be able to check that consent for an examination has been obtained. The Polnay report, Health Needs of School Age Children, also recommends that consent for the school health programme should be obtained at school entry.2It gives no guidance, however, on whether specific consent should be obtained for some components of the programme such as medical examinations and immunisations, and makes no comment about consent for school health activity provided by therapists and others which is outside the core programme. If consent is to be valid, it must be informed and specific for a particular treatment or programme of health care. It is difficult to see how consent obtained for a 4–5 year old could remain valid throughout that child’s school career.
Annual consent has enabled us to provide parents with better information about school health services and has raised the profile of school health staff. Despite the increased workload for clerical staff and school secretaries, the new arrangements have been welcomed by the great majority of parents and schools. All those involved feel they are establishing partnerships with parents rather than delivering a hidden service which only gives feedback when problems are suspected. It remains to be seen whether the high return rate of consent forms can be maintained.
Drs Chambers and Panting comment:
We thank Dr Smith for her comments which support our view that doctors whose practice includes children should be aware that they are not exempt from the ethical and legal requirements involved in consent for physical examination—whether the patient is accompanied or unaccompanied. Dr Smith’s account illustrates this amply. We deliberately did not ‘touch on’ specific problems or deal with individual specialties or clinical circumstances, but wished to provide a general framework.
Readers may be interested to read a statement from the Amercian Academy of Pediatrics Committee on Practice and Ambulatory Medicine concerning the use of chaperones in paediatrics.1-3
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