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Next steps in shaping the future of specialised gender identity services

Much work continues in NHS England to shape the future of specialised gender identity services. We have convened a Programme Board for Gender Identity Services that I chair.

The Board is responsible for making recommendations to the Specialised Commissioning Oversight Group, and its scope and membership can be found on the gender identity services clinical reference group page. The Board’s independent members were appointed through an open recruitment process.

I’m pleased to announce the publication of the report of the independent analysis of responses to our consultation on proposed service specifications. We had significant interest in the consultation – over 800 respondents, and I want to thank everyone who took part either in writing or by attending one of our events.

We are now in the process of forming the final proposals for the service specifications. The Clinical Reference Group for Gender Identity Services received the report in December, and having considered the report, it submitted its final advice on the specifications to NHS England in March. We are considering the CRG’s advice alongside the independent report and individual consultation submissions, with a view to publishing a final version of the specifications in the Spring of 2018.

The quality of the submissions to consultation was high, and has given us a rich source of ideas and proposals to consider. Alongside the process for finalising the service specifications we are also exploring potential models of care and models of delivery, and I will keep you updated by way of this blog.

I will also share with you over the next few months the process for the national procurement of specialist surgical and non-surgical services that is planned for the summer of 2018. We hosted a market engagement event in March for organisations interested in taking part in the procurement, where we described the emerging ambitions for procurement.

I will write again shortly with another update, but in the meantime I will endeavour to answer your questions via this blog as quickly as I can.

Join the conversation #nhsgenderid

James Palmer

James Palmer has been Medical Director for Specialised Services since NHS England’s inception in 2013. He is a member of NHS England’s Specialised Commissioning National Team. He is a Consultant Neurosurgeon at Plymouth Hospitals NHS Trust.

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37 comments

  1. Lauren Mackenzie says:

    Hi James
    When are NHS England planning to put gender services out for procurement? Could you also tell me how a provider can register interest in this process?
    Many thanks

  2. Caroline Smale says:

    I have just checked The Laurels Exeter GIC website.
    Their updated wait times now list 30 months to a first appointment, and a further 26 months before starting any treatment.
    Over 4 1/2 years from referral to starting treatment is beyond a disgrace.

    What IS the NHS doing to address this scandalous situation?

  3. J. Evans says:

    The new NHS England Gender Services Spec. just released Sep./2018 says ‘Self referral now permitted by the individual provided individual is registered with a GP.
    However the Spec. gives NO Clarity how such a referral is made ?

    Does individual choose a GIC then – write in by letter ? or via email ? or contact by telephone ?
    Can someone please clarify ?

  4. Sophie Cee says:

    Looks like the specifications are out. just received this email:


    VOICE-CRG, England (NHS ENGLAND)
    11:09 (3 minutes ago)
    to

    Dear Registered Stakeholder

    You are being sent this email because you have registered you interest on our database for Gender Identity Services.

    Today NHS England published new service specifications for specialised gender dysphoria services. Alongside the specifications is a consultation report that explains how the submissions to the public consultation held in 2017 influenced the development of the specifications. NHS England would again like to thank everyone who took part in the public consultation and associated events that were held. The documents may be found by following this link:

    https://www.engage.england.nhs.uk/survey/gender-identity-services-for-adults/

    Regards

    Clinical Task Team (Medical Policy)
    (Specialised Commissioning)”

  5. jeremy luke says:

    Well done Michael, I had considered doing this myself, but as I work in the system I preferred not to.
    I would be very grateful if you were able to post the reply on here.
    Best wishes
    Jerry

    ps James, if you are still here it would be good to hear from you

  6. Michael says:

    I have now submitted a freedom of information request for an update, since it appears that NHS England does not intend to supply an update of its own initiative.
    https://www.whatdotheyknow.com/request/adult_gender_identity_service_co

  7. Jerry says:

    Hi James
    I don’t know if you have moved from this job or just avoiding the blog. Either way it would be kind of you to let us know.
    As Spring and summer have passed and are drifting into a beautiful Autumn could we have some idea of when NHSE will let us see the commissioning specifications?
    I would be in a great deal of trouble with my regulator if I went this long without letting those dependant upon me know what was happening

  8. Niamh says:

    It’s now September – close to four months since this update was published – and no updates have been provided for any of the “next steps” discussed here, most of which are now well past the expected timeframes that were outlined in your post.

    When will “the final version of the specifications” that was supposed to be published by July appear?

    When will “the national procurement of specialist surgical and non-surgical services” that was supposed to happen over the summer actually take place?

    There are serious problems with NHS England’s gender identity service provision. It’s been over two and half years since the Women and Equalities Committee Report on Transgender Equality, which highlighted many of these problems was published. Why are the promises made by NHS England in the government’s response to that report still largely unfulfilled? Why, two and a half years on, is NHS England still failing trans people?

    • Sophie Cee says:

      honestly this. and in the meantime i keep seeing James Palmer chip in his professional opinion in a variety of other contexts. the bare minimum he could do is use his public facing blog to explain why the time frames, THAT HE EXPLICITLY LAYS OUT, are not being met.

  9. Michael says:

    Hi James. It’s now late August and there is still no sign of the service specification. As a consequence, the procurement exercise will presumably not be launched in line with suggested timescales.

    In the meantime, one experienced chest surgeon for trans men does not have a valid NHS contract (as he changed provider), while a second has recently stopped performing chest surgery. Some patients have been caught up in this twice, meaning they have been waiting for years, on two different waiting lists, and are now facing starting from scratch for a third time. This is significantly affecting people’s mental health.

    Can you please update us as to what is happening, an estimate of the new timescales and (preferably) consider temporary action, such as offering interim NHS contracts to experienced private surgeons?
    Thank you.

  10. Richard kerry says:

    Hi James, you say things are moving forward within the specialised services for gender identity care, yet the fact that gender transitioning is 90% social & 10% medical and that there is no acnowlegement that services like voice therapy needs to be intensive,image consultancy to strengthen affirmation of gender, more than just 8 laser hair removal sessions, much less of a stereotypical view of gender presentation from those that judge patients following the care pathway. All I ever hear is about waiting time reduction rather than the giant leap that this service needs in the care pathway. Rather than the care pathway focusing on surgery in terms of judgement of rediness, instead of putting the cart before the hourse, provision of support for the social transition as stated above is needed and can’t be left up to peer support groups (as the WPATH guidlines state the social transition can be psychologically damaging) yet the nhs does nothing to in terms of the services meantioned above.

  11. Nicola says:

    Hi James
    August 2018 is nearly over do you have a revised date for the release/publication after all Clinical Reference Group for Gender Identity Services received the report in December 2017, this delay is causing undue stress to people waiting for Transgender services provided under the NHS. what is the reason for the delay?

  12. Jerry says:

    sad that you can talk to the BMJ but not to us

  13. Jerry says:

    Hi James
    Could you let us know where things are with this specification?
    Within the South of England there are many patients confused and distressed by the lack of any coherent plan for their care, and we are not yet able to offer them any clear answers

  14. Sophie says:

    Hi,

    As the planned publication of specification by “spring” and then “july” have both passed, i take this that this represents yet another delay in this already delayed process.

    Could we be advised of the new timeframe?

  15. Niamh says:

    So, it’s August. What happened to “publishing a final version of the specifications in the Spring of 2018”? Or the plan to “publish the service specifications by July”?

  16. Jason Fraser says:

    Hi James,

    Whilst this service will be commissioned as a specialised service, has there been any thought as to what level of GP input may be required to deliver a seamless service for patients? Will GPs who are currently in a position where they are currently prescribing medication to this group still be responsible for this under the current service specification or will the service itself be picking up the prescribing?

  17. Holly says:

    Hello James,
    thank you for letting us know that you will be publishing a final version of the specifications in the Spring of 2018.
    Since today, 21 June, is the last day of Spring 2018, please could you let us know where the specifications are published?

    thank you,
    Holly

  18. Holly says:

    In October 2017, Prime Minister May said the Government will seek to “streamline and de-medicalise” the process of changing gender to reflect that “being trans is not an illness”.
    The law presently states that being trans actually is an illness (Gender Recognition Act(2004) Section 25 Paragraph (1) sixth sentence). It is surely understandable that NHS England acts on a basis of existing law rather than laws HM government proposes to enact. Thus NHS offers treatment for “gender dysphoria” as defined in law.
    We all, including NHS, must recognise that medical treatment of people who have already changed legal sex “for all purposes” (GRA2004 9(1) ) is entirely different from the medical treatment of people aspire to change their legal sex, as many patients presenting with a trans condition do. “All purposes” includes medical purposes, something too often overlooked.
    And therefore if and when the law on gender recognition is changed as in Ireland (so Mrs. May proposes) the NHS will have to majorly reform its policies on sexual medicine in every trans context.
    I hope that partly explains why existing policies are as they are and why there is great hope for the future.

  19. Vicky-Jane Gooding says:

    I notice that multiple submissions were accepted from one IP Address. An IP Address is assigned to one individual broadband account by the Internet Service Provider so indicates that one internet account has made multiple submissions. The report states that each submission was different and so in included, however this surface level analysis only indicates that the submissions were not made by a robot it does not rule out one individual seeking to manipulate the the outcome. These submissions should be highlighted in the report as coming from the same IP Address and so likely from one person so that their influence can be assessed before the final report.

    • Nikki says:

      Many people who have internet access at home may have several persons wishing to express their views from that ip address. It doesn’t necessarily mean some one has been submitting more than once. In my house there are 5 of us so my IP might appear 5 times as my partner and our kids express their views.Also a university may have several students using a “drop in” computer room and that IP will appear many times.

  20. Harmonie says:

    Hi James ,
    Why have we been silently ethnically cleansed?.
    I along with a large number from all around the country & other places whom identify similar to myself have been involved in the commissioning process & events for several years.
    Given that the GRA was at it’s outset developed & created for TS people.
    Why is every other group allowed to be recognised to be having considerations, thoughts etc , yet we are not mentioned once anywhere in your report ?.
    I like many others identify has a Transsexual female . It has a very definitive meaning which illuminates that for us it is not a lifestyle choice , for many it is life or death .
    The terminology embraces where we have come from & where we are heading or become grounded eventually .
    I truly hope it was a genuine oversight & not discrimination by disclusion by you or indeed the way forward by the NHS as a whole .
    There is no distinction between TG & TS in the report undermining our credibility & our meaningful transitions.
    Harmonie

  21. Jerry says:

    Although I understand this is to be a ‘specialised commissioning’ review it would be useful to know what GP involvement there is in the CRG.
    GPs have had to deal with many reports that decide for GPs what they ‘must do’ without checking what GPs are actually contracted to do.
    I had a look at the CRG page and cannot work out whether the CRG has generalist input or not.
    Perhaps you could let us know before the Spring gives way to Summer?

    • NHS England says:

      Dear Jerry
      I understand that Will Huxter has responded to you on this point on previous occasions. There is no GP on the Clinical Reference Group, but as the consultation guide explained, we have sought views from relevant primary care organisations including the BMA’s General Practitioners’ Committee. The process of consultation offered individual GPs, Local Medical Committees, local Prescribing Committees and national organisations the opportunity to take part in the process, and I am pleased that there was such a significant response from the primary care workforce. My conversations with primary care organisations are continuing.
      Kind regards
      James

  22. Carl Brown says:

    I hope notice will be taken of the many gender critical comments you report. A watchful waiting policy should be followed rather than rushing to prescribe medication and surgery to young people. What happens if these people change their minds?

    • NHS England says:

      Dear Carl
      The final version of the service specifications will be informed by a careful consideration of the views submitted during consultation though, as the independent report highlights, there were often opposing views. I will keep you updated by way of this blog.
      Kind regards
      James

  23. Tara de Boumtier says:

    ..But if Theresa May says transgender is not an illness.. Why is the NHS offering surgical and cosmetic treatments to healthy-bodied people who are ‘not ill’? If they are ill, in what way are they ill? Does the NHS offer these treatments to all body dysphoric people or is it just ‘gender identity’ you are so concerned about?

    • NHS England says:

      Dear Tara
      Interventions for the alleviation of gender dysphoria are prescribed by Ministers as services that are commissioned directly by NHS England as specialised services. A description of the basis for the clinical need and benefit to the individual is a thread that runs through the proposed service specifications. The specifications also describe the criteria to access the various interventions on the NHS pathway of care.
      James

  24. Michael says:

    Hi James. Very please to see that the consultation has been reviewed and the revised service specification will be amended and published shortly (although ‘Spring 2018’ seems ambitious – you’ve only got two weeks!)

    With regard to the procurement exercise, please do bear in mind that patients who are already six months into a two year waiting list may feel unsettled and even distressed if they hear that the service they are waiting to access is up for re-contracting. It would be valuable if communication on the subject could provide clear reassurance that there will be no interruption to care, and that key NHS principles such as patient choice and prompt access to care will remain central.

    Many thanks
    Michael

    • NHS England says:

      Dear Michael

      Thanks for your comments.

      Yes, indeed, the reference to “Spring” should read “Summer”. The plan is to publish the service specifications by July. I take your point about the need for clear and effective communication.

      Kind regards
      James

  25. Diana says:

    Any news on facial feminisation surgery to help with dysphoria in patients, particularly important around issues of mental health and acceptance.

    • NHS England says:

      Dear Diana

      Thank you for your question.

      We explained in the Guide to Consultation that was published last year that the scope of a service specification does not include the introduction of treatments that are not currently routinely commissioned by NHS England. Rather, a separate process exists for this purpose and we have asked the Clinical Reference Group for Gender Identity Services to establish the evidence base that may support a clinical commissioning policy for this intervention, for adoption in 2019/20. I will keep you updated by way of this blog.

      Kind regards

      James

  26. Nicola says:

    Will there be changes to the electrolysis treatment available for transgender male to female and if so what are the changes thank you.

    • NHS England says:

      Dear Nicola

      Thank you for your post.

      There will be no changes to current arrangements in the immediate term but in response to consultation submissions that suggested that our current policy was inadequate for many individuals we have asked the Clinical Reference Group for Gender Identity Services to advise us on future commissioning arrangements for facial hair epilation services based on a review of the available evidence. The plan is to adopt a new clinical commissioning policy from 2019/20 but at this stage I cannot say what those changes may be. However, any proposed changes will be supported by a separate process of stakeholder engagement and consultation with registered stakeholders. If you are not registered as a stakeholder you may do so here.

      Kind regards

      James

      • Hiary says:

        I hope the review of facial hair removal will look at outcomes and not costs as a primary factor in decision making. As transgender professional hair removal practitioner I can confirm that electrolysis (electro epilation) is the only permanent process for all hair types. I treat many trans clients who have undertaken laser treatment which has not permanently stoped hair growth. The 2013/14 draft proposal stated up to 240hrs of electrolysis should be offered. The 8 sessions refered to in the proposed review is a meaningless figure. Currently there is a funding limit which will not allow for a successful outcome see https://goo.gl/XyjHNb

  27. Finn says:

    Hi James,

    Can you tell me whether non binary gender is going to be recognised by the NHS? Currently I am forced to choose between either male or female on my records. I have a diagnosis of non binary gender dysphoria having to choose between male or female is extremely distressing.

    Also, one of the most popular top surgeons, Mr [name removed by administrator] has lost his current NHS contract, leaving many of his patients in limbo as there is no news on when he is getting a new contract. For people who have waited for top surgery for years and years this is very upsetting.

    Kind regards
    Finn

    • NHS England says:

      Dear Finn

      Thank you for your post.

      The service specifications reiterate the rights of individuals who meet the criteria to use these services to exercise full personal autonomy in respect of their gender identity and presentation, including a non-binary presentation. The Specialised Commissioning Team at NHS England has no influence over the recording of gender on NHS or other official records.

      In regard to your second point, the future configuration of organisations that will provide surgical interventions will be determined through a transparent and open process of competitive procurement that we plan to launch in the summer. I will keep you updated by way of this blog.

      Kind regards

      James