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NHS England’s plans for the future commissioning of gender identity services for adults
Welcome to my latest blog on gender identity services. As always, I aim to cover issues that are current, and are important to the planning and delivery of gender identity services, and what we need to do to ensure that the services that we commission are responsive and high quality.
In this blog I’m going to share with you an outline description of the process that NHS England will use to decide which organisations will host the adult gender identity clinics and the specialist surgical elements of the gender identity pathway in the future.
NHS England will do this by running a national procurement of adult gender identity services, as described in our recent commissioning intentions for specialised services for 2017-19.
I wrote to all of the current providers of gender identity services this week to state our intention to formally serve notice of termination on all of the NHS and independent sector organisations with whom we currently hold contracts for the delivery of specialised gender identity services (surgical and non-surgical), for the purpose of re-tendering the award of contracts via a process of national procurement in 2017. The current providers of gender identity services will be able to bid for the award of a new contract.
Organisations which are bidding for the award of a new contract will have to demonstrate that they are able to deliver the requirements of the new service specifications for adult services. We plan to consult on at least two new service specifications (for surgical and non-surgical services) in the New Year, following a further process of stakeholder engagement.
Why are we doing this?
Firstly, we need to follow a procurement process to identify a new host for the gender identity clinic currently delivered by West London Mental Health NHS Trust, which is England’s largest gender identity clinic (I wrote about this in my previous blog). This provides us with an opportunity to transform the way in which gender identity services are commissioned and delivered across the country. As many people have stated, change is essential if we are to be successful in reducing the historically long (and unacceptable) waiting times, and improve the patient experience in other important ways.
In recent years NHS England has worked with all of the providers of gender identity services in England to begin to address long waiting times, including the provision of significant additional funding in these services. But given the forecast continued growth in demand, and the national shortage of appropriately trained professionals, we know that additional investment in itself is unlikely to solve the waiting time problem, nor will it improve other aspects of the patient experience that we know are important to people who use these services.
We also need to be conscious of the report of Parliament’s Women and Equalities Select Committee’s inquiry, published in January 2016, criticising the delivery and commissioning of gender identity services, including: inconsistent clinical protocols; inequitable access arrangements; out-dated approaches to service delivery; and the absence of a consistent application of clear and appropriate standards.
Therefore, NHS England has asked the Clinical Reference Group for Gender Identity Services to make recommendations on new service specifications for gender identity services. What we need are proposals that will stimulate innovation and transformation in the gender identity services along the entire patient pathway, in order to achieve even better outcomes for people who use the services. This will include, in the longer term, recommendations on outcome measures against which to assess the safety and quality of services along the pathway. We will use the procurement process to provide assurance that the organisations with whom we hold contracts in the future have demonstrated an ability and willingness to deliver services in accordance with the new specifications.
I appreciate that any process of change may cause some anxiety for the dedicated staff who work in these services and for the people who use them, but please be assured that we are very clear that we do not expect that at any point there will be a reduction in the level of service provision as an outcome of this process. Our intention is to address the capacity and demand problems and to address the equity issues that we commonly hear from people who use the services.
I will write again with further details, including timescales for engagement and consultation, in a future blog.
The process that I have described will not include the Gender Identity Development Service for children and young people. We will continue to explore innovative ways to increase capacity in this service and address access issues, and we will review the need for any formal procurement process once we have implemented the new service specifications for adult services.
Hi Will, The new NHS England Gender Services Spec. came into force 2019. This states that ‘Sel Referral to A NHS Gender Clinic is now allowed from individuals ( who are registered with a GP ). However Charing Cross Gender Clinic still does NOT accept such self referrals from individuals. Can you say why they do NOT adhere to the new Spec. ??
Jan Evans. GICRG.Member.
I wonder what other healthcare provision consultation would result in a quarter of the replies being that the service should be less available, more rationed, harder to access and be increasingly pathologised?!
I hope that commissioning services would look to disregard the comments of those who have ideological hostility to the very concept of gender identity, as being in bad faith.
At the very least they should fall outside the remit of the consult. I suspect if i contributed to a consultation on say knee surgery in order to comment that knee surgery was erasing the existence of ankle joints, that my comments would not be taken seriously.
“I will write again with further details, including timescales for engagement and consultation, in a future blog.”
While I’m sure I can’t imagine the incredible pressure placed on NHS England staff, generally but especially over the last several years, I’d like to point out that it’s been over half a year since this last blog and I had hoped ‘future blog’ meant far sooner than that.
I’m afraid it feels like information and engagement has substantially reduced since 2016. Personally, I’d deeply appreciate more readily available, publicised updated on progress, process, etc rather than a trickle of disparate information from many sources. Even a short summary of activity would be good, in my mind.
It is understandable that waiting times need to be dealt with, but there is still a huge lack of understanding with regard to professionally guided support during the required social transition (RLE) with the gic’s assuming that pier support from monthly group meets to be adequate. The whole point of transitioning for most patients is to be able to be as passable as humanly possible but the gic’s expect patients to start the RLE without adequate support in changing their outward appear ance, 1) inadequate amount of hair removal sessions 2) facial surgeries (considered to expensive) despite obvious need in a large amount of patients) 3) lack of deportment training 4) the belief that voice training is more effective after significant change to appearance (singers do not train their voice for a song after the event).5)The laurels clinic’s mental health team are only counselors not fully trained specialist psychotherapists.
Is there to be any provision for gender dysphoria care in the NW? I was referred by my GP to a GUM unit
Thanks for your question.
We are conscious that there is currently no local specialist gender identity clinic in the North West of England, although people in the North West can be referred to any of the clinics elsewhere in the country. One of the objectives of the national procurement will be to address access issues, but we can’t be specific at this stage about what the outcome of the procurement process will be as this will depend on how the procurement is structured, which new organisations decide to bid, and whether existing providers will submit bids that set out plans to broaden their geographical coverage.
In any event, we have asked the Clinical Reference Group to deliver a new service specification that describes a network based approach to patient care and that introduces innovative models of delivery so that there are fewer demands on patients having to make unnecessary journeys to the gender identity clinic.
Thank you for your concise reply. I am on hold at present for another reason not connected with it but I am thinking of proceeding
Now 2018 and I have been referred to Leed GIc and have a screening interview early in Augusr
We are working in partnership with local trans organisations, other NHS Trusts and Public Organisations to address some of the issues that trans people face when using our services. We are developing an event – one of the objectives is: To influence and support change in the way services are commissioned.
Is there a way that we could link with the work that you are undertaking?
Please feel free to write to me with further details. Will Huxter, Regional Director of Specialised Commissioning (London), 1st Floor, Skipton House, 80 London Rd, London SE1 6LH.
I was referred to a GUM clinic for a chat with a specialist that was 6 months ago and we agreed to come back 6 months later and I have another appointment early in December. I don’t want physical change but peace and I am advised modest estrogen may be helpful. What will happen now. I am 81 with other problems under treatment.
I have responded to your subsequent post of 24 November.
oh dear. the website is broken again.
I ask difficult questions and the they fall off the screen.
lets see if this goes through and then i can re-post
I feel a hint of discrimination entering into this blog.
Yesterday you answered several posts but not mine about GP involvement , nor that of Samantha Payne about waiting lists or Dr Richards about gamete storage.
Could you set out for us the thinking behind this blog?
What is its purpose?
Dear Dr Luke
I’m sorry if responses do not appear as quickly as you would wish. I aim to provide responses to all outstanding posts at the same time, but some questions require further consideration before answering.
Thanks for this Will.
Just what constitutes a reasonable time for further consideration?
As a GP I provide same day consultations for all of my patients if needed. Routine appointments at the patients convenience are at about 2 weeks.
Can you let me know what NHSE offers?
Dear Dr Luke
Thanks for your further post.
People who are transitioning get really cross at long waiting times and lack of transparency about what the NHS will provide and within what timeframes.
People who post on your blog get cross about the annoyed by the same problems.
So; simple question.
What input have you arranged from GPs to ensure that the new contracts for GICs will actually work in the real world (real lived experience)?
I find this a disgraceful thing. years of stakeholder work down the tube and no consultation or prior information given to the broader stakeholder group that has been meeting and discussing this for over 3 years. It is doing nothing for the trust of the community or those that support them.
Thanks for your post.
I’m sorry you feel this way, but I don’t agree that what we are doing represents a rejection of all of the valuable stakeholder work. In fact, at numerous meetings of the Transgender Network I have heard people call for a national re-procurement precisely along the lines that we are proposing. And other responses to this blog show that there is support for the proposal within the community.
In terms of consultation and engagement, the considerable engagement to date is shaping the work of the Clinical Reference Group and the numerous working groups in drafting the service specifications, and there will be further engagement and consultation in the new year. Please check out future blogs for details of how to get involved.
And what does this mean for those already on a very long waiting list? Even longer waiting list? If my centre I have been referred to does not get a new contract do I have to go back on another list and wait a further year before being seen? This makes me sad that you plan to terminate all contracts leaving many people with no service to turn to for help or no idea where they will be going.
Thank you for your comments.
I can assure you that no one will be left without a service, and no one will have their waiting time extended as an outcome of the process. One of the objectives of this process is to reduce waiting times, for both the gender identity clinics and the surgical units, and NHS England is continuing to work with all providers this year to address the waiting time problem.
There seem to be quite a few unanswered questions on your blog, including mine.
I understand that you are busy but some of these are actually quite important.
Can you give us some idea of the timescales to which you are working?
Dear Dr Luke
Thank you for your post.
As you know, I do try to respond as soon as I can to all respondents. I have said in my blog that I will write again with a more detailed description of the timeline, and I will do that once it is available.
“What we need are proposals that will stimulate innovation and transformation in the gender identity services along the entire patient pathway”
My proposal is to fund gamete storage as a core funded treatment rather than the postcode lottery of CCG [non]funding which currently happens. Indeed some CCGs have protocols specifically written to exclude trans patients.
This effectively amounts to a eugenic approach as trans people are unable to have their own biological children if they have not already done so when starting hormones or having some surgeries.
Can we have your assurance that gamete storage for trans people will be core funded, or the commissioners instructed to fund via CCG in all cases please?
I think it’s important for the wider audience reading this blog to know that you are a member of the Clinical Reference Group (CRG) for Gender Identity Services. As you know, from recent discussions of the CRG, NHS England’s service specification for gender identity services can only include treatments that Ministers have agreed are specialised and for which NHS England has commissioning responsibility. The specification cannot therefore include gamete storage as this is not a specialised treatment, and is not one that NHS England is responsible for commissioning. This is a treatment funded by Clinical Commissioning Groups. It is for each CCG to determine its own commissioning position for its local population.
Dear Will. Enjoy reading your blogs. According to Imperial College website – there are 318 patients on waiting list with 40 new referrals in Sept. Only 7 ops done at Imperial but 22 by private provider. I would like to offer my service for Gender Surgery.
Christopher Inglefield FRCS(Plast)
Specialist Gender Surgeon
Dear Mr Inglefield
All interested organisations will be required to follow the same process of bidding as part of the planned procurement, once the new service specifications have been agreed in the new year.
By serving termination notices on all GICs, what is that likely to mean for patients on the current pathway?
I know people who have just had their first GIC appointments, and others who’ve just had their referrals for surgery. Will this revised method interrupt these services in any way?
Thanks for your post.
No patients will have their planned treatments interrupted as an outcome of any changes to current contractual arrangements.
An obvious truth that is going unaddressed is that most (but not all) gender transitioners are modernly accepted as having no mental disorder whatsoever – and yet the lion’s share of the budget for Gender Identity services goes to psychiatry.
Psychiatry for people who have no mental disorders is a huge waste of money. Gender clinics should be moved from Mental Health services to Sexual Health services with a remit to refer the minority of patients who actually do need psychiatry appropriately.
Not only would this hugely reduce the cost of providing gender services but it would free up psychiatrists to work where they are genuinely needed.
Thank you for your comments.
NHS England is clear that gender dysphoria is not a mental health disorder. The protocol that we currently use to commission the Gender Identity Clinics describes a multi-disciplinary team approach, with no requirement for a psychiatric assessment. The focus of the protocol is in ensuring that assessment and treatment is flexible in response to individual needs and circumstances.
Glad to see a possible overhaul of services as the current system is clearly not fit for purpose.
I feel GP’s need to be empowered and encouraged to dispense hormones and to provide monitoring. As a transgender m2f I feel my needs are not very different to those GPs are familiar with in prescribing and monitoring hormones.
For adults a process based on informed consent needs to replace the reliance on ‘experts’ (for hormones); this would significantly cut waiting times. Currently I still have 4 months (of 14) to go before a first London GIC appt and I guess another 6-7 months before hormones might be prescribed. Needless to say that is way too long and I have had no choice but to go private. I have no view on what the process might be for GRS but accept this needs to be ‘expert based’.
We also need to move to being able to self define gender and not need to apply to some official body. No one can define my gender other than me.
Thanks for your post.
NHS England’s current commissioning protocol in regard to prescribing hormones is adapted from the World Professional Association for Transgender Health guidelines, and requires the specialist multi-disciplinary team to ensure that individuals meet certain eligibility and readiness criteria before taking the decision to refer to the GP for prescription of hormones.
We will publish the proposed new service specifications in the New Year for the purpose of public consultation.
Two points – as CE of a trust providing such services I have received no such letter. And secondly your blog here may well have been seen by our staff already before we’ve had any chance to speak to them to allay their understandable fears when they read formally give notice etc
Since you posted, our respective offices have established that the letter was addressed to your nhs.net account. I’m sorry for this oversight.
are you taking questions on this blog?
I notice that you are ignoring difficult questions on your previous blogs.
That may be your interaction of choice, if so it would be useful if you let us know.
Dear Dr Luke
I’ve responded to the questions posed on my previous blog, and I do try to respond to everyone who takes the time to post comments as soon as I can.
Thanks Will, you did indeed answer one of my questions.
Can you let me know what involvement there will be from General Practice into the new GIC service specifications.
I am sure you are aware there are currently significant tensions between what the GICs think GPs will do and what most GPs are professionally able to do.
Sensible service specifications would go a long way to alleviate these problems