Introduction

NHS England is committed to improving and expanding gender services for children and young people to ensure that they receive safe, responsive, holistic care.

The Cass Review was an independent review of NHS gender identity services for children and young people, commissioned by NHS England in 2020. The final report from this review was published in April 2024.

This pack outlines the steps that NHS England has already taken guided by interim advice from Dr Cass and sets out how we will take forward the recommendations made in the final report.

In this document the recommendations from the Cass review are cross referenced.

An introduction from Dr Hilary Cass

Waiting for NHS treatment is tough for everyone who finds themselves in that position. I know that those of you who are waiting for help with gender-related distress have faced a particularly worrying and uncertain time as services have been in a state of flux. NHS England has taken this situation very seriously, and I am pleased that they are planning to fully implement the recommendations of my Review.

The vision of the Review – reflected in the NHS England implementation plan – is to increase available services for gender-questioning young people.

Those services will take a holistic approach to care which addresses the needs of each individual and will put in place a full package of care which can be delivered as close to home as possible.

We don’t know enough about who might benefit from medical interventions as part of their package of care, but if the clinical team think that this may be the right pathway for an individual, they will have access to those treatments as part of a carefully constructed research programme; this approach will give a better evidence base for future generations of young people.

In order to make things better in the future, NHSE needs the support and engagement of all the young people and families using these services, so I do hope that despite the frustrations and challenges that everyone has faced, there will be a real collaboration in developing the model of care together.

This implementation plan from NHS England is an important milestone in improving care, but the NHS now needs to focus on delivering additional capacity and an improved service offer to this group of patients.

Dr Hilary Cass

The two year action plan

Section 1: current progress

Steps already taken to respond to the interim advice from the Cass Review

Deployment of a Multi-Professional Review Group (MPRG)

An independently chaired Multi-Professional Review Group was established to review all referrals of children under 16 for a hormone intervention. This step ensured that a proper process had been followed by the Tavistock and Portman NHS Foundation Trust, including for informed consent and safeguarding procedures.

A new interim service specification published

An interim service specification was published which describes how the new services will take a more cautious approach to assessment, diagnosis and intervention, including social transition particularly for younger children; and that the primary clinical approach will be psychosocial and psychological rather than medical.

Tavistock GIDS was brought to a managed closure

NHS England brought the Gender Identity Development Service (GIDS) at the Tavistock and Portman NHS Foundation Trust to a managed close. As part of this, the waiting list was temporarily transferred to NHS England while new services are established.

Two new national Children and Young People’s Gender Services opened in London and the North West in partnership with leading tertiary paediatric providers

The new NHS Children and Young People’s Gender Services became operational in April 2024, in the North West and London. The initial focus has been on the children and young people who were transferred to them from the closed Tavistock and Portman NHS Foundation Trust service.

Established a Research Oversight Board to oversee an academic strategy

The National Research Oversight Board includes the National Institute for Health and Care Research and a range of key experts in research is guiding the approach to a comprehensive programme of research.

National clinical policy for puberty suppressing hormones

A new clinical commissioning policy was adopted that prevents the prescribing of Puberty Suppressing Hormones to children and young people under 18 years of age for children and young people who have gender incongruence or gender dysphoria due to the limited evidence around safety, risks, benefits and outcomes.

National clinical policy amendments for gender affirming hormones

NHS England also made consequential amendments to the existing clinical commissioning policy for gender affirming hormones pending a full review of the evidence in 2024, to stipulate that a national Multi-Disciplinary Team with an independent chair will review all referrals of young people for Gender Affirming Hormones (replacing the role of the Multi-Professional Review Group).

Training and education delivered by the Academy of Medical Royal Colleges

To support the establishment of new services, NHS England commissioned the Academy of Medical Royal Colleges to design and deliver the induction training for new clinical staff.

A specification changing the referral pathway into the CYP gender service

Through publication of a service specification that describes access arrangements to the national waiting list, the NHS confirmed that from 1 September 2024 all new referrals to NHS Children and Young People’s Gender Services must be made through NHS secondary care services (mental health or paediatric services) to ensure that every child or young person has a thorough assessment of need, and that those who need it receive appropriate support from local teams while they remain on the waiting list. The new services will establish how support is given to families of younger children as close as possible to the referral date.

Section 2: implementation

Next steps – putting the recommendations into action

1. We will establish a specialist gender service based in a children’s hospital in each of the seven regions in England.
2. We will publish a refreshed service specification for the specialist gender services, to incorporate the findings of the final report from the Cass Review.
3. We will support the new specialist gender services in forming a National Provider Collaborative so that there is a consistent approach to service delivery, research and clinical audit.
4. We will build a new clinical workforce that is trained through an education framework that is aligned to the new clinical model.
5. We will support the specialist gender services in establishing a regional network of local services that will include primary care, mental health services and paediatric services.
6. We will establish a wide-reaching research programme that will increase the evidence base.
7. We will ensure that there is a seamless interface with adult gender services for those young people for whom this is an appropriate step.
8. We will define an NHS pathway for those individuals who choose to detransition

Implementation – additional new services

Step 1: We will establish a specialist gender service based in a children’s hospital in each of the seven regions in England.

• Following on from the establishment of two new NHS Children and Young People’s Gender Services in April, the NHS will continue to appoint up to six additional new providers between 2024 and 2026 on a phased basis.
• The next new service to become operational will be in Bristol in November 2024. This new service will initial take patients from across England and Wales, but move to offer services to the South West and South Wales populations over time.
• Cambridge University Hospitals NHS Foundation Trust is working with NHS England on plans for a regional service for the East of England, with an anticipated start date of spring 2025.
• The new services will have a nominated medical practitioner (paediatrician or psychiatrist) who has overall clinical responsibility for patient safety within the service. Recommendation 1.

• NHS England is supporting potential new providers in developing costed mobilisation plans that form the basis on which they are awarded NHS contracts to deliver these new services. The key challenge in mobilising new services is the need to recruit and train a new clinical workforce, hence the need to build the new configuration of providers on a phased basis.
• To help encourage clinical staff to work in this field, and to maintain a broader clinical lens, NHS England has agreed for the new providers to offer contracts for clinical posts as joint appointments, thereby enabling clinical staff to work across different services and across their regional networks. Recommendation 13.
• The full cost of these posts, including the element that is not deployed to gender services, is met by NHS England.

Implementation – service specification

Step 1: We will publish a refreshed service specification for the specialist gender services, to incorporate the findings of the final Cass Review.

• NHS England will update the Interim Service Specification in 2024 to reflect the final advice of the Cass Review. As usual the NHS will involve the public and service users, through a process of stakeholder engagement and public consultation, with the new service specification becoming operational on 1 April 2025.
• The service specification will propose that clinicians should apply the assessment framework developed by the Cass Review to ensure children and young people receive a holistic assessment of their needs to inform an individualised care plan including screening for neurodevelopmental conditions, and a mental health assessment. Recommendation 2.
• Standard evidence based psychological and psychopharmacological treatment approaches should be used to support the management of associated distress and co- occurring conditions. Recommendation 3.
• A revised clinical policy for gender affirming hormones will define how a medical pathway might be entered ensuring that consistency and persistence of incongruence is a core pre-requisite. Recommendation 7.
• The service specification will propose that all children are offered fertility counselling. Recommendation 10.

Implementation – provider collaborative

Step 3: We will support the new specialist gender services in forming a National Provider Collaborative so that there is a consistent approach to service delivery, research and clinical audit.

• A key objective is that as the new regional providers come online to deliver children and young people’s gender services they all join up as a provider collaborative. Recommendation 12 and 31.
• While NHS England will initiate the work defined in this pack, there are elements that will need to be continuously led by services themselves. The objective here is that a learning healthcare system is baked into the commissioned services.
• The collaborative will start to function in October 2024 with three regional centres and will be expanded to include all providers.
• Month by month, elements of this implementation plan will be handed over to the collaborative.
• With the continued advice from Dr Hilary Cass, as a special advisor, the collaborative will bring in leaders from professional societies, education, and research.
• Through building on the evidence of all interventions the aim of the objective is to embed an iterative, data-driven approach to service improvement.
• The NHS recognises that it can be difficult for families to navigate the various sources of advice and information that exist about children and young people who present with issues of gender variance.
• Often this information is inaccurate and may encourage behaviours or actions that may not actually be in the best interests of the child or young person, such as sourcing hormones drugs from unregulated sources or unregulated providers. NHS England will update the NHS.uk webpages on ‘gender dysphoria’ to reflect the findings of the Cass Review, and the National Provider Collaborative will coordinate development of evidence-based information and resources for young people, parents and carers. Consideration will be given as to whether this should be a centrally hosted NHS online resource. Recommendation 16.

Implementation – workforce development

Step 4: We will build a new clinical workforce that is trained through an education framework and that is aligned to the new clinical model.

• NHS England commissioned the Academy of Medical Royal Colleges to design and deliver the initial training for new clinical staff.
• In May 2024 NHS England established a Training and Education Working Group, and this group will commission an expert third party that will develop a competency framework for staff in tertiary services and secondary care and develop a suite of training materials to supplement professional competencies. Recommendation 15.
• The Training and Education Working Group includes representation from NHS England’s Workforce Training and Education function (formerly Health Education England) and as such the group is well- placed to advise NHS England and professional associations about how to ensure that workforce requirements for children and young people’s gender services are built into overall workforce planning for adolescent services. Recommendation 14.

Implementation – regional networks

Step 5. We will support the specialist gender services in establishing a regional network of local services that will include primary care, mental health services and paediatric services.

• Each regional network will be formed around a range of collaborating services that provide care in the local community in an integrated way with the regional tertiary gender service. Recommendation 11.
• The ambition is that, for many children and young people, appropriate specialist care can be provided closer to home in community settings rather than at a specialist children’s hospital. NHS England supports the ambition of the recommendation, and in recognition of the scale of the challenge, it will work with key partners over 2024/25 to draw up a detailed framework that regional systems of care can use to form regional implementation plans from 2025/26.
• These key partners will include Integrated Care Systems, professional associations including those representing primary care clinicians, senior clinical leaders and patient and public voice representatives.
• Given that it will be critical for there to be a designated tertiary provider that is well established as a pre- requisite for the development of a regional matrix of services, the roll- out of the new regional model will be on a phased basis from 2025/26 and will be subject to the outcome of considerations around financial affordability and other local priorities.
• Being mindful of the advice of the Cass Review that the current evidence base suggests that children who present with gender incongruence at a young age are most likely to desist before puberty, this work will ensure that within each regional network, a separate pathway will be established for pre-pubertal children and their families so that these children and their families are seen for early discussion. Recommendation 22.

Implementation – research

Step 6. We will establish a wide-reaching research programme that will increase the evidence base.

• NHS England agrees with the Cass Review’s conclusions that the evidence base underpinning medical and non-medical interventions in this clinical area must be improved. Future research studies will include academic evaluation of psychosocial interventions. Recommendation 6.
• The National Research Oversight Board for Children and Young People’s Gender Services will lead on work to establish a full programme of research that aims to embed standard approaches to audit, research and evaluation in the new service model.
• This will include the establishment of a living systematic review that will be in place by April 2025, in conjunction with academic partners and the National Institute for Health and Care Research, that will continuously review new relevant research as it becomes available. Recommendation 21.
• The National Provider Collaborative will take the lead on the approach for delivery of clinical management and future research activities in this field so that there is a consistent approach including the establishment and delivery of a unified research strategy. Recommendation 20.
• A prioritised portfolio of research will be built using the James Lind Alliance Future research studies will include academic evaluation of psychosocial interventions.
• NHS England will support the providers (including through financial investment for specific posts) in ensuring that the academic and administrative infrastructure to support a programme of clinically- based research is embedded in the new services. Recommendation 19.
• NHS England has assumed responsibility from the Cass Review team to complete a study that links the data from the services provided by the former Tavistock GIDS to an adult data set. Recommendation 5.
• This required legislation from the Secretary of State for Health and Social Care (statutory instrument) to be laid that allowed the linkage of the NHS number given at birth and the new NHS number after a change of gender recognition.
• Such studies can provide a wealth of knowledge that may lead to greater understanding of long-term health benefits and harms.
• Explorations are underway to be able to complete this study with the cooperation of the CEOs and CMOs of the NHS trusts that host the adult gender services.
• In order to realise the ambition for a national infrastructure to be put in place to manage data collection and audit for the purpose of driving continuous quality improvement and research, it will be vital for the new providers to be collecting, analysing and reporting a consistent and meaningful data set. Recommendation 18.
• Under the auspices of the National Research Oversight Board, the new providers will agree a core national dataset that will be in use by September 2024. Recommendation 17
• A national data repository will be established by April 2025.
• In addition to its use in a research context, the enhanced approach to data collection and reporting will support NHS England regional teams in their management of the contracts held with the providers of the services. Recommendation 30.
• The National Research Oversight Board continues to oversee the process for establishing a clinical study into the potential benefits and harms of puberty suppressing hormones for children and young people with gender incongruence, in partnership with the National Institute for Health and Care Research.
• Professor Emily Simonoff has been confirmed as Chief Investigator for the study.
• The research will be co- sponsored by King’s College London and the South London and Maudsley NHS Foundation Trust. The study protocol should be complete by December 2024 and, subject to academic approval, recruitment to the trial would commence in early 2025.
• NHS England has established a Youth Advisory Network that began to meet in May 2024, and which has as members children, young people and their families. The focus has been to provide the patient and public voice element to the of study design.

Implementation – adult services

Step 7: We will ensure that there is a seamless interface with adult gender services for those young people for whom this is an appropriate step.

• NHS England has started to explore with potential partner organisations the feasibility of establishing a follow through service for 17-25-year-olds as a pilot for evaluation. Recommendation 23.
• This work will require NHS England to identify a provider organisation/s that is/are able to deliver the pathway, define a delivery model including though a proposed service specification for the purpose of public consultation, and to design the evaluation framework prior to the establishment of the service. As such the current planning assumption is that this follow-through service will become operational no sooner than April 2025.
• Further development of the design of this part of care will be informed by NHS England’s systemic review of adult gender services.
• Prior to the publication of the final Cass Review, NHS England had already announced that it was bringing forward its planned update of the service specification for adult gender services and has since described a broader review of the model of care and operating procedures. Recommendation 24
• NHS England has published details of this review, with the aim of the new service specification for adult gender services being adopted no earlier than April 2025 following a process of stakeholder engagement by the autumn of 2024, followed by a process of public consultation.

Implementation – detransition

Step 8: We will define an NHS pathway for those individuals who choose to detransition.

• There is no defined clinical pathway in the NHS for individuals who are considering detransition. NHS England will establish a programme of work to explore the issues around a detransition pathway by October 2024. Recommendation 25.
• The exploration will include: an examination of the incidence of detransition and the reasons for detransition; a consideration of the support needs and the interventions that may form the elements of a clinical pathway; and workforce considerations including the extent to which, if any, there is a role for specialists in gender dysphoria – recognising that individuals who choose to detransition may not wish to re-engage with the services they were previously under.

Implementation – working with other agencies

Several recommendations highlighted the importance of organisations working together collaboratively to take forward actions. These are some examples of how NHS England is working with government.

• NHS England/Department for Health and Social Care (DHSC)/private providers: The boundaries between privately funded care and NHS care will be defined. Recommendation 26.
• DHSC: The DHSC and Secretary of State have enacted powers to control the dispensing of puberty suppressing hormones from primary care and private providers, and through prescribers in Europe. Recommendation 27.
• DHSC: Further exploration of the issue of changing NHS number, the implications for clinical care and the ability to monitor life-long harm. Recommendation 28.
• DHSC: The Cass Review concluded that the Tavistock GIDS was implementing ‘innovative’ changes in care without a well- considered evidence base. The Cass Review calls for steps to be taken so that the same rigour is applied to all innovation delivered by clinical services as is the case for new medicines and devices. Recommendation 32.

Glossary of terms

• Consent: Permission for a clinical intervention (such as an examination, test or treatment) to happen. For consent to be ‘informed’, information must be disclosed to the person about relevant risks, benefits and alternatives (including the option to take no action), and efforts made to ensure that the information is understood.
• Detransition: The process of discontinuing or reversing a gender transition, often in connection with a change in how the individual identifies or conceptualises their sex or gender since initiating transition.
• Endocrine services: Sometimes referred to hormone treatment/therapy services. In relation to this clinical area, this term is used to describe the use of gonadotropin-releasing hormones and feminising and masculinising hormones.
• Gender affirming hormones: Also known as masculinising and feminising hormones, these are sex hormones given as part of a medical transition for gender dysphoric individuals (testosterone for transgender males and oestrogen for transgender females).
• Gender dysphoria: Diagnostic term used by health professionals and found in DSM-5 outlined above (American Psychiatric Association, 2013). Gender dysphoria describes “a marked incongruence between one’s experienced/ expressed gender and assigned gender of at least 6 months duration” which must be manifested by a number of criterion.
• Gender incongruence: Diagnostic term used by health professionals, found in the WHO International Classification of Diseases ICD-11. Gender incongruence is characterised by “a marked and persistent incongruence between an individual’s experienced gender and the assigned sex”.
  Gender variance A broad term used to describe the way in which an individual’s sense of gender identity varies from their natal sex.
• Gonadotropin releasing hormone analogues: Also known as hormone blockers and puberty blockers; taking these hormones stops the progress of puberty. The GnRH analogues (puberty blockers) act by competing with the body’s natural gonadotrophin releasing hormone. This competition blocks the release of two gonadotrophin hormones important in puberty called Follicular Stimulating Hormone (FSH) and Luteinising Hormone (LH) from the pituitary gland.
• Neurodevelopmental conditions/disorders: The World Health Organization criteria (2022b) defines neurodevelopmental disorders as “behavioural and cognitive disorders that arise during the developmental period that involve significant difficulties in the acquisition and execution of specific intellectual, motor, or social functions”.
• Paediatrics: The branch of medicine dealing with children and their medical conditions.
• Primary care: Primary care in the UK includes general practice, community pharmacy, dental and optometry (eye health) services. This tends to be the first point of access to healthcare.
• Psychosocial: Describes the psychological and social factors that encompass broader wellbeing.
• Puberty blockers: See: Gonadotropin releasing hormone analogues.
• Puberty suppressing hormones: See: Gonadotropin releasing hormone analogues.
• Secondary care: Hospital and community health care services that do not provide specialist care and are usually relatively close to the patient. For children this will include Mental Health Services, child development and general paediatric services.
• Service specification: A service specification clearly defines the standards of care expected from organisations funded by NHS England to provide specialised care. The specifications are developed by specialised clinicians, commissioners, expert patients and public health representatives to describe both core and developmental service standards.
• Social transition: A process of changing the outward expression of a person’s gender by changing things like their name, pronouns, clothing, appearance and activities. According to the Cass Review’s interim report, it is important to view it as an active intervention because it may have significant effects on the child or young person in terms of their psychological functioning.
• Specialised services: NHS specialised services support people with a range of rare and complex conditions. Three factors determine whether NHS England commissions a service as a prescribed specialised service. These are: the number of individuals who require the service; the cost of providing the service or facility; the number of people able to provide the service or facility.
• Tertiary services/care: Tertiary care is the specialist end of the NHS. These services relate to complex or rare conditions. Services are usually delivered in a number of specialist hospitals/centres.

Publications reference: PRN01451