To: Dr David Levy, Independent Chair of the Review of Adult Gender Clinics

Dear Dr Levy,

We would like to thank you and your panel for your important work conducting this independently led review into the operation and delivery of NHS Adult Gender Dysphoria Clinics.

NHS England is committed to supporting people who need these specialist services and that is why we commissioned this review. Waiting times have remained unacceptably long and this is not just distressing for patients but also for those staff working within these services whose motivation is to provide the very best care they can.

We also wanted to better understand variation in practice between services; the opportunities for improving quality – clinical effectiveness, safety and experience – across services; and the challenges facing the clinical teams providing these services, whether that be adjusting to the needs of a changing demographic or managing the growing waiting lists.

Your final report, together with its findings and recommendations directly responds to these challenges and presents a clear framework from which a comprehensive plan of action can be taken forward.

As you know, we have not simply sat back and waited for your report before taking action to improve these services. Since the review was commissioned NHS England has:

• established a National Improvement Programme to share best practice and learning across services and support urgent quality improvement efforts within services. We are pleased to see that your report recognises this as an important mechanism for tackling many of the issues identified by the review;
• commissioned a new adult gender service in Cheshire and Merseyside, following an evaluation as a pilot. This has increased the number of newly commissioned and additional services to three since 2023. A provider selection process is currently in train to establish a fourth new regional service for the East of England by April 2026
• formed detailed plans for creating a new single, national waiting list for adult gender services to be implemented in April 2026. This will allow us to support meaningful demand and capacity modelling at provider level and support the regionalisation of the Adult Gender Services (most of which have historically operated as national services); and achieve greater transparency about who is on the waiting list to support clinical risk reduction measures.

In addition to the above, the government has also announced a new support service for some of the longest waiters in the country.

Next steps

NHS England, in full partnership with the Department of Health and Social Care, will now lead the next stage of the system-wide response.

We will establish a National Portfolio Board, in line with your recommendation, to build and develop a full implementation plan, which will address each of your recommendations in turn and be aligned with the ambitions of the Government’s 10 Year Health Plan for England. It will describe how the National Quality Improvement Network for Adult Gender Services will reinforce its use of experienced quality improvement (QI) practitioners, embedded in each of the Adult Gender Services, to secure a standardised and impactful approach using established QI techniques and tools. The Network will also seek to embed a culture of quality improvement in the NHS Adult Gender Services from Board to clinic.

Immediate priorities will also include:

• raising the referral threshold to 18 years to align with the age of discharge from the NHS Children and Young People’s Service;
• bringing an end to self-referrals into the service and, in parallel, providing advice and guidance for those finding it difficult to secure a referral;
• establishing challenging but achievable productivity goals for every service which can then guide and inform the commissioning of additional services, underpinned by a clear understanding of the regional demand through the national waiting list;
• changing the role of the Adult Gender Services, so that patients are discharged from the service at an earlier stage of the clinical pathway and for the surgical units to take on responsibility for assessment of suitability for surgery;
• working with professional bodies to establish a new professional role of GP with an Extended Role in Gender Medicine, to provide support to those who have completed their care within the Adult Gender Service clinics and provide leadership and knowledge sharing with primary care in every neighbourhood;
• redesigning the financial framework for Adult Gender Services, moving away from block contracts to incentivise efficiencies and clinical activity;
• extending the role of the existing National Research Oversight Board for Children and Young People’s Gender Services to cover research and audit activities relating to the adult pathway;
• defining the role of integrated care boards in the adult gender pathway, and support them in implementing your recommendations.

Importantly, your report has highlighted a need for the providers of these services to improve productivity quickly and to rapidly implement recovery actions. To that end, we are pleased that you have accepted NHS England’s offer to take on  the role of independent chair of a newly formed national provider collaborative for Adult Gender Services, that will begin its work in January 2026. In this role you will work with NHS England and the Department of Health and Social Care in supporting the Adult Gender Services in a coordinated and systematic approach to quality improvement and productivity recovery. 

We thank you and your team for leading this important review. Your report will help us to improve both services and the lives of the patients who need them. 

John Stewart, National Director, Specialised Commissioning, NHS England
Professor James Palmer, Medical Director, Specialised Commissioning, NHS England