Policies like the one operating in Dr Williams' surgery where under-16-year-olds must be accompanied by a parent or guardian can be detrimental to the health of children and young people and should be avoided. Children and young people need to be able to access health services confidentially and for those who do not want to share their personal health information with a parent or guardian, this means being able to access them alone.
Doctors should therefore make it clear that they are available to see children and young people on their own if that is what they want. This is particularly important in the area of sexual health: concern about confidentiality is the biggest deterrent when it comes to young people asking for sexual health advice. If young people don't feel able to seek advice about sexual health, that presents a danger to their health, that of other young people and the health of the community as a whole. Parents may not be aware that their child is sexually active, but it is clearly in the child's best interests to have access to care and advice where necessary.
Dr Williams offers Sarah a chaperone, even before she knows what the consultation is likely to be about or if it might involve an intimate examination. Sarah declines. 0-18 years: guidance for all doctors recommends doctors think carefully about the effect the presence of a chaperone can have: they can deter young people from being frank and open, and they may not be as likely to ask for help with what's really troubling them. In Sarah's case study, the chaperone offered is known to her; in fact she is the mother of her classmate. This may be the reason Sarah declines. Had an alternative chaperone been available, Sarah might have accepted the offer.
As with any patient, the doctor must decide whether the child or young person is competent to make decisions about treatment. This is why Dr Williams makes sure that Sarah understands the implications of taking the pill and of not taking the pill, the risks and side-effects, other options for contraception, before she prescribes it for her. If she had not found that Sarah had capacity to consent, she would not have been in a position to prescribe, although she should still have kept the consultation confidential.
Though Dr Williams tries to persuade Sarah to speak to her parents, in the end she decides to prescribe the pill without their knowledge. This is because she judges that Sarah understands the implications, and that she is likely to continue to have sex whether or not she prescribes the pill. That would run the risk of unwanted pregnancy and Dr Williams judges that Sarah's best interests are served by prescribing the pill.
When Sarah comes back to the surgery a second time Dr Williams is concerned that the relationship she has with her boyfriend Paul may be abusive. 0-18 years: guidance for all doctors states that if a child or young person is involved in abusive or seriously harmful sexual activity, the doctor must protect them by sharing relevant information with appropriate people or agencies, usually children's social services. Although it may seem that parents would be the obvious people to disclose to in these circumstances, doctors should consider the potential adverse consequences. Doctors must also consider the impact that such a disclosure and its consequences could have on other young people and their trust in doctors.
As with any disclosure, the doctor should tell the child or young person what they propose to disclose, to whom, and why. The only exception to this is if informing the child of the disclosure would undermine the purpose (for example if they are likely to help an abuser evade the police) or if it would place them at increased risk of harm. Dr Williams fortunately manages to persuade Sarah to come back for an appointment with her mother. If she hadn't succeeded in this, and if Sarah had refused consent to involve an appropriate third party, Dr Williams would need to carefully consider Sarah's reasons for refusing consent to disclose.
In the end, however, doctors' first concern must be the safety and welfare of children and young people. They must promptly inform an appropriate person or authority of any reasonable concern that a child or young person is at risk of abuse. Whether a doctor decides to disclose or not, they should record their decision and the reasoning behind it. Doctors will be able to justify raising a concern, even if it turns out to be groundless, if they do so honestly, promptly, on the basis of reasonable belief, and through the appropriate channels.