Professional standards, training and membership.
Professional standards, training and membership.
Ethics in IEMT Practice: Lesson 3.1.2
Understanding Gillick Competence
Welcome
“Gillick competence” is a phrase you will hear often when people talk about children and consent, but it is easy to misunderstand. This lesson explains where it comes from, what the test actually asks, where its limits lie for IEMT practitioners, and how to apply it carefully and keep a record of your reasoning.
Learning Objectives
By the end of this lesson, you will be able to:
- Explain what Gillick competence is and where it comes from.
- Describe the questions you can use to judge whether a young person under 16 can consent to a decision.
- Recognise the limits of Gillick competence in non-medical practice, including insurance.
- Balance a competent young person’s wishes with safeguarding and the role of parents.
- Record your assessment clearly.
Where Gillick competence comes from
The name comes from Gillick v West Norfolk and Wisbech Area Health Authority, a House of Lords decision of 1985 about whether doctors could give contraceptive advice and treatment to girls under 16 without their parents’ knowledge. The Lords held that they could in some circumstances. Lord Scarman explained the principle in a sentence that has been quoted ever since:
parental right yields to the child’s right to make his own decisions when he reaches a sufficient understanding and intelligence to be capable of making up his own mind on the matter requiring decision.
Lord Scarman, Gillick v West Norfolk and Wisbech Area Health Authority [1985] UKHL 7; [1986] AC 112
You may also hear of the Fraser guidelines. These come from Lord Fraser’s judgment in the same case and relate only to contraception and sexual health advice. “Gillick competence” is the wider principle that a child’s ability to consent depends on their understanding, not simply on their age.
What the test asks
There is no set age at which a child becomes competent. The question is whether this child can make this decision. Competence depends on the individual’s maturity and understanding, on how complex and serious the decision is, and on how they are feeling at the time. A child may be competent to agree to something simple and not competent to make a more serious decision. Competence can also change from day to day, for example when a child is very distressed.
A useful way to explore it is to ask whether the young person can:
- Understand what you are proposing, why, and what it might involve.
- Retain that information long enough to make a decision.
- Weigh it up, including benefits, risks, limits and alternatives (including doing nothing).
- Communicate their decision clearly, and understand that they can change their mind or stop at any time.
These are the same questions we use for adults in Lesson 2.1. For a young person the emphasis is on whether they truly understand, and whether the decision is really theirs, not shaped by pressure from a parent, a friend or you.
The limits of Gillick competence for IEMT
Be careful not to treat Gillick as a licence. It was decided in a medical setting, by judges looking at doctors and contraceptive advice. Courts have not decided how it applies to non-medical practitioners such as IEMT practitioners, and views differ. In particular:
- The Association’s policies do not set a minimum client age. They require you to work within your training, competence, insurance and lawful scope, and to follow the Safeguarding Policy.
- Your insurer may set its own age limit, or may not cover you for work with under-16s at all, or may require parental consent whatever the child’s maturity. Ask in writing.
- Gillick is about consent, not about demand. A competent young person can consent to what you offer. They cannot require you to provide it, and it does not stop you from acting to protect them.
- Practicalities matter. Someone usually has to pay for sessions and bring the child. Think about how secrecy could work, and whether it is wise.
The Association’s policies set no minimum client age, so their general rules apply. Three matter most. First, the four-part scope test: you need the training and competence for this client group, and insurance that covers it (Scope of Practice Policy, sections 2 and 5). Second, consent: where capacity or legal consent is uncertain, do not proceed until the applicable requirements are understood and met (Standards of Competence, section 4). Third, safeguarding: a child is anyone under 18 (Safeguarding Policy, section 2).
In practice, if you cannot be sure that a young person can consent alone, the clear route is consent from a person with parental responsibility, with the young person told what is happening in words they understand. If you are considering seeing a competent under-16 without a parent’s involvement, take advice from your supervisor first (Standards of Competence, section 5), and record how you decided: your training and competence, your insurer’s written confirmation, the advice you took, your Gillick-style assessment and your safeguarding plan. Young people aged 16 and 17 are treated differently, as explained in Lesson 3.1.
How to assess competence in practice
Explore competence through your first conversation and keep checking as you go. You might ask:
- “Can you tell me in your own words what we are going to do?”
- “What do you think might be good about it, and what might be difficult?”
- “What would happen if you decided not to go ahead?”
- “What would you like to happen? Is this your own choice?”
- “Do you know you can stop or ask for a break at any time?”
Listen for understanding rather than for the “right” answer. If you are unsure, or the case is borderline or complex, get supervision or other advice before you go ahead.
Balancing competence and safeguarding
A young person can be Gillick competent and still be at risk. Competence does not remove your safeguarding duties. If a competent young person tells you they are being harmed, or you think they are at risk of serious harm, you may need to break confidentiality in line with the Safeguarding Policy (see Lesson 3.3).
Also think about:
- whether the young person has enough support outside your sessions;
- what is lost if parents or carers are left out, and what is gained if they are brought in (with the young person’s agreement where possible);
- whether the young person is under pressure from someone, including someone who wants the sessions to happen.
Working with parents and a competent young person
If a competent young person asks you to keep something confidential, you should respect that unless there is a risk of serious harm. Even so, it is good practice to encourage openness with parents or carers when that is safe, explain the limits of confidentiality at the very start, and reassure the young person that you will always act in their best interests.
Examples
| Situation | What to think about | Suggested approach |
|---|---|---|
| A parent brings their 8-year-old and asks for sessions. | The child is too young for Gillick to be a realistic route. The parent’s consent is needed. | Check your insurance and competence for this age. Obtain consent from a person with parental responsibility, explain things to the child in words they understand, and listen to their view. |
| A 14-year-old contacts you directly and says they do not want their parents to know. | Gillick competence, your insurer, safeguarding risk, who is paying, why the secrecy. | Do not agree to secrecy. Take advice. Explore why they want secrecy and whether they are safe. Follow the working position above before offering any session. |
| A 15-year-old seems mature, and their parent refuses permission. | Whether the young person is truly competent; the parent’s position; the risk of conflict and harm. | Take advice before going any further. Do not work against a parent’s clear refusal without understanding the legal and insurance position. |
| A 17-year-old attends alone. | Presumed to have capacity (Lesson 3.1). | Treat as you would an adult, but still think about maturity, circumstances and safeguarding. |
Documentation and supervision
- Record your assessment and the reasons for your conclusion, in the young person’s own words where you can.
- Record the young person’s understanding and consent.
- Note every conversation with parents or carers.
- Use supervision whenever you are in doubt, especially in complex or borderline cases.
Gillick is a decision of the House of Lords on English law and is followed in Wales. In Scotland the Age of Legal Capacity (Scotland) Act 1991 gives a person aged 16 or over legal capacity to consent to medical treatment, and says that a younger person has capacity where, in the opinion of the qualified medical practitioner attending them, they are capable of understanding the nature and possible consequences of the treatment. In Northern Ireland the Age of Majority Act (Northern Ireland) 1969 provides that consent by a person aged 16 or over to medical treatment is as effective as an adult’s, and the Mental Capacity Act (Northern Ireland) 2016 is being brought into force in stages. Outside the UK, the legal age for consent differs, so check local law.
Self-Reflection Exercise
Test your understanding:
- Why can a 14-year-old be Gillick competent for one decision and not for another?
- What would you need to have in place before working with a competent under-16 without a parent’s involvement?
- How would you explain your confidentiality limits to a 15-year-old who asks you to keep a secret?
Key Takeaways
- Gillick competence asks whether this young person can make this decision, not what age they are.
- There is no set age, and competence can change over time and with the decision.
- It was developed in medicine, and its application to IEMT is untested. Your insurer’s conditions and the Association’s safeguarding policy still apply.
- Competence never removes safeguarding duties.
- Record your assessment, and get advice when in doubt.
Next Steps
Lesson 3.2 looks at communicating with young clients and keeping clear, safe boundaries.