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Chapter 4 of 11 · Ethics, Law & Safeguarding
Children: Gillick, Fraser and parental responsibility
Three ages, two tests that are constantly confused, and one asymmetry that has survived every attempt to overturn it.
Start with the age
| Age | Consent | Refusal |
|---|---|---|
| 16–17 | Presumed competent to consent by statute — Family Law Reform Act 1969 s8 in England and Wales, the Age of Majority Act (NI) 1969 s4 in Northern Ireland, and full legal capacity at 16 under the Age of Legal Capacity (Scotland) Act 1991 in Scotland. Parental consent is not needed. If they lack capacity, the Mental Capacity Act applies — it starts at 16. | Not protected by s8. A refusal of life-saving treatment can be overridden by the court. Whether a parent can override is legally unresolved in England, Wales and NI — and not available in Scotland. |
| Under 16 | May consent if Gillick competent for that decision. | Same asymmetry, and on weaker ground still. |
| Any age | If not competent, consent comes from someone with parental responsibility, or the court. |
Three different ages to keep straight: 16 — statutory consent, and the MCA begins. 18 — advance decisions, LPAs, DoLS. Any age — Gillick competence, which has no lower limit.
Gillick and Fraser are not the same thing
This is the single most-confused pair in the whole syllabus, and it is confused in textbooks as well as in exams.
Gillick competence comes from Gillick v West Norfolk & Wisbech AHA [1986] AC 112. A child under 16 who has “sufficient understanding and intelligence to enable him or her to understand fully what is proposed” can consent in their own right. It applies to any treatment decision, sets no fixed age, is decision-specific, and can fluctuate.
The Fraser guidelines are the five criteria Lord Fraser set out in the same case, and they apply only to contraception and sexual health advice and treatment (extended by Axon to STIs and abortion). The young person:
- cannot be persuaded to inform their parents, or to allow you to;
- understands the advice;
- is very likely to begin or to continue having sexual intercourse with or without contraceptive treatment;
- is likely to suffer physically or mentally without the advice or treatment;
- and it is in their best interests to receive it without parental consent.
A 14-year-old needing an appendicectomy is a Gillick question. A 14-year-old asking for the pill is a Fraser question. If a stem about a fracture or a vaccination offers “apply the Fraser guidelines”, it is the distractor.
A 15-year-old attends alone and asks to start the combined oral contraceptive pill. She has a 16-year-old boyfriend, is clear about the risks and benefits, and does not want her mother told.
Which framework applies, and what do you do?
You do need to satisfy yourself she has sufficient understanding — that is Gillick. But because this is contraception, the Fraser criteria are the specific test, and you should work through all five and record them.
Work through all five criteria and document them. Encourage her to involve a parent, but you may not tell them without her agreement. Assess for exploitation using the age gap and the relationship dynamic; a 15-year-old with a 16-year-old partner and no coercive features is ordinarily low concern.
Also cover: STI screening, emergency contraception awareness, and safeguarding — the confidentiality you offer is not absolute (see Chapter 5).
R (Axon) v Secretary of State for Health [2006] EWHC 37 (Admin) confirmed this: parents have no right to be notified where the Fraser criteria are met. Breaching her confidence would be unlawful and would deter her and others from seeking care.
If you have a conscientious objection you must tell her, without expressing disapproval, and refer promptly to someone who can help. But you cannot simply decline and you must still keep the consultation confidential.
Pick an option to see the answer.
The consent/refusal asymmetry
A competent young person can consent. A competent young person cannot necessarily refuse. This looks incoherent, and it has been criticised for thirty years — but it is still the law.
The Court of Appeal reviewed it in E & F (Minors: Blood Transfusion) [2021] EWCA Civ 1888 and confirmed that Re W survives both the Human Rights Act and the Mental Capacity Act, that there is no presumption in favour of the mature adolescent’s decision, and that welfare is the overriding principle. It also expressly left open whether a parent can consent where a competent 16- or 17-year-old refuses — calling it “at best questionable”.
Safe practice: where a competent young person refuses treatment that is genuinely necessary to prevent death or serious harm, apply to the court. Do not rely on a parent’s signature to do it for you. In Scotland, parental override is not available at all.
Parental responsibility
Parental responsibility (PR) is the bundle of rights and duties that lets someone consent for a child. Knowing exactly who has it is a recurring exam item and a recurring real-world problem.
| Who | Parental responsibility? |
|---|---|
| Mother | Always, automatically. |
| Father married to the mother at the time of birth (or later) | Yes. |
| Unmarried father named on the birth certificate | Yes — but only if the birth was registered on or after 1 Dec 2003 (England & Wales) or 4 May 2006 (Scotland), or the child was born on or after 15 April 2002 (Northern Ireland). Every child under 18 today is past all three dates, so in practice the two questions are: were the parents married, and is he named on the certificate? |
| Unmarried father, birth registered before those dates | No — unless acquired by PR agreement, PR order, subsequent marriage or a court order. |
| Step-parent, grandparent, adult sibling | No, by default. Only via agreement, adoption, special guardianship or a court order. |
| Local authority with a care order | Yes, shared with the parents. |
| Foster carer | No. |
How many have to agree?
One is legally sufficient — each PR holder may act alone (Children Act 1989 s2(7)). But there is a short list of decisions where the courts expect agreement from all PR holders, or an application to court if they disagree:
- Non-therapeutic male circumcision
- Sterilisation
- Contested immunisation — the Green Book is explicit that where one parent agrees and the other disagrees, the immunisation should not proceed unless they can agree
The immunisation rule cuts the other way for the child themselves: a Gillick-competent child or a 16–17 year old can consent to vaccination and a parent cannot override that consent, even where both parents object. Competence beats parental disagreement; parental disagreement beats parental consent.
A 4-year-old needs sutures under sedation. He attends with his father, who has never been married to the mother and is not named on the birth certificate. Mum is at work and is not answering her phone.
Can the father consent?
Parental responsibility is a legal status, not a biological fact. An unmarried father acquires it by being named on the birth certificate at registration, by a parental responsibility agreement with the mother, by a PR order or a child arrangements order naming him as the person the child lives with, or by later marrying her. Being the father is not enough on its own.
Not being on the certificate is not the end of it — ask him directly. Many fathers in this position have a PR agreement, a PR order or a child arrangements order and do not describe it in legal terms.
Practically: if he has none of those, keep trying the mother. In a genuine emergency you may treat without consent under the doctrine of necessity — but sutures under sedation for a stable child can usually wait the twenty minutes it takes to reach her.
For the exam, note the registration dates in the table above — and note that they no longer bite for anyone currently under 18.
Any PR holder may consent, acting alone. The mother is not privileged — she simply always has PR.
One is enough. The short list requiring agreement is non-therapeutic circumcision, sterilisation and contested immunisation.
Pick an option to see the answer.
Confidentiality for under-16s
A competent child is owed the same duty of confidence as an adult. A parent has no automatic right to see the record of a competent child, and cannot demand disclosure of a consultation.
You may disclose without consent where there is an overriding public interest, where it is in the best interests of a child who lacks the maturity to decide, or where the law requires it. Tell the child what you propose to disclose and why, unless doing so would place them at increased risk.
Sexual activity: the ages that matter
- The age of consent is 16 across the UK.
- Under 13: absolute. A child under 13 cannot in law consent to any sexual activity, and there is no defence of reasonable belief about age. The GMC says you should usually share information about sexual activity involving a child under 13.
- 13–15: risk assessment, not automatic reporting. Look at the age and power gap, the partner’s position of trust, coercion or pressure, use of substances, and whether the partner is known to have abused children. Share where the activity is abusive or seriously harmful.
Self-testA 15-year-old tells you she is in a sexual relationship with a 24-year-old teaching assistant at her school. She asks you not to tell anyone. What do you do?
You share. Two features make this abusive rather than a peer relationship: the age and power imbalance, and the fact that he is in a position of trust — abuse of position of trust offences protect 16- and 17-year-olds, so the concern is greater still at 15.
Tell her what you are going to do and why, before you do it, unless that would put her at increased risk. Refer to children’s social care, document her words verbatim, and involve your practice safeguarding lead and the ICB named GP.
Self-testA 17-year-old with anorexia nervosa, BMI 12, refuses admission. Her parents want her admitted. What is the legal position?
First test capacity under the MCA, which applies from 16. Anorexia frequently defeats the “use or weigh” limb even where understanding and retention are intact — if she lacks capacity, a best-interests decision follows and the Mental Health Act may be needed.
If she is found to have capacity, her refusal is not automatically determinative because she is under 18. The safe route is an application to the court under the inherent jurisdiction — not a parental signature, which E & F described as at best questionable where the young person is competent.
Puberty blockers. Since 1 January 2025 the Medicines (Gonadotrophin-Releasing Hormone Analogues) (Restrictions on Private Sales and Supplies) Order 2024 has restricted private sale and supply of GnRH analogues for puberty suppression in under-18s across the UK. It is legislation, not just NHS policy — but note what it does not do: NHS prescriptions and clinical trials sit outside it, patients already established on treatment before June 2024 (August 2024 in Northern Ireland) are excepted, and the Order carries a statutory review due by 1 October 2027.
And one duty that belongs here even though it is covered in Chapter 6: if a girl under 18 tells you FGM has been carried out on her, or you see physical signs of it, that is a mandatory report to the police — the only statutory personal reporting duty a GP has in this area.
Written and checked by NHS GPs. Last reviewed 24 August 2026. UK law and guidance change — always follow current local policy and your defence organisation’s advice in a real case.
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