Foreword from the Chair

In June 2024, NHS England asked me to lead a review of all 9 commissioned NHS adult gender dysphoria clinics (GDCs) in England. My task was to consider whether these services met the requirements of the current non-surgical interventions service specification and the needs of patients seeking their support.

Throughout my career, I have been concerned with improving health services by better understanding patient needs and delivering the best clinical outcomes. My work has aimed to improve the experiences of both patients and the healthcare staff supporting them.

I brought these same principles to this review. It was clear from the start that these services face significant challenges and that NHS England’s Specialised Commissioning team was serious about further improving access while also ensuring that the services remain safe and effective in delivering clinically appropriate interventions and care.

Understanding the potential opportunities for service improvement requires a range of professional perspectives. In undertaking this review, I was supported by an expert panel comprising representatives from relevant professional bodies, the Care Quality Commission, regional and integrated care board (ICB) commissioners, as well as a group of peer reviewers from the GDCs, who did not review their own services.

Between October and December 2024, the panel conducted 1-day visits to each of the 9 GDCs. We examined evidence provided both in advance and during these visits to identify challenges, recognise best practice and pinpoint where improvements could be made against key lines of enquiry.

Hearing directly from transgender patients significantly enhanced our understanding of the services provided by individual GDCs. Each visit began with representatives from patient workshops presenting the key themes from their group discussions. These conversations underscored the critical importance and high value placed on these clinics by the patient population they serve.

The review also surveyed patients, their families, friends, and GDC staff. This approach ensured a range of voices informed our findings.

These services are commissioned to provide a clinically appropriate response to patient need, and I would like to thank all those who gave their time to help develop an understanding of how these services operate.

Gender service provision is an area where there are strongly held views about how care should be delivered and who should provide it. These services have to navigate this challenging landscape, where debate is often hostile and polarised, while continuing to provide patient care. This context also affects patients’ expectations and creates challenges for staff undertaking their professional responsibilities. We should not lose sight of the fact that at the heart of this are patients seeking NHS support and healthcare professionals working to help them achieve their best possible outcomes.

With patients and GDC staff in mind, it’s important to highlight that this review was conducted with a future-facing focus on improvement, and our work was guided by a commitment to compassionate, safe and high-quality clinical care.

At the end of this process, the review has revealed that care provision in these services does not meet the service specification, nor does it meet the needs of the current patient cohort. This stems from failings within the services themselves, as well as in part from the long-term effects of demand far outstripping supply and a lack of joined-up care across the wider healthcare system.

As detailed in the key findings, every service requires immediate improvements in 1 or more of the 4 following areas: access (with a focus on waiting times); quality (including safety); productivity; and culture, leadership and governance.

The ambition should be that all patients receive the same standards of timely, high-quality assessment and care, regardless of the GDC they attend. Standards should be consistent with other NHS services, with levels of risk managed to ensure care is not only safe but meets each patient’s needs and supports them in achieving their best outcomes.

This report represents the findings of the review panel and highlights opportunities to bring these services in line with other NHS services. The responsibility for responding to these findings and supporting these patients extends across the whole healthcare system, beyond that of just national specialised commissioners. Integrated care boards (ICBs) need to ensure there is access to appropriate local services across the full range of healthcare to meet these patients’ holistic and longer-term healthcare needs.

Throughout the course of this review, I have witnessed some innovative approaches to improving care provision, including the use of multidisciplinary teams and technology. These improvements and efficiencies have delivered tangible benefits for patients and staff, with a marked reduction in long patient waiting times.

Building on these successes requires all commissioned adult GDCs to actively engage with the National Quality Improvement Programme for Adult Gender Services. Supported by their boards and a whole-system response, this will enable a wider adoption, embedding and scaling of effective practices to drive sustainable change.

NHS England will wish to carefully consider how best to implement the review’s recommendations. This work must be underpinned by collaborative engagement and co-ordinated action from the national and local commissioning teams alongside the adult gender dysphoria clinics, NHS trusts, ICBs, primary care and other constituents of the healthcare system. This will help ensure the necessary improvements in patient care.

Dr David Levy, Chair, Operational and delivery review of NHS adult gender dysphoria clinics

About this review

Scope of the review

Commissioned by NHS England Specialised Commissioning team in July 2024, this operational review of NHS adult gender dysphoria clinics (GDCs) in England was led by Dr David Levy, with the support of a panel of clinicians and other key stakeholders. The aim was to:

• determine whether the operation and delivery of the GDCs meet the requirements of the non-surgical interventions service specification
• consider the safety and effectiveness of the GDC service

The review examined:

• the operating procedures in each of the 9 NHS-commissioned adult GDC services
• how the current service model meets the needs of patients across the pathway
• challenges to GDC service delivery
• any existing action to improve quality, including effectiveness, safety, patient experience and unexplained variations in care

The review aimed to identify:

• areas for improvement in relation to GDC service quality and to inform an update of the non-surgical interventions service specification
• good practice that could be shared by GDCs
• support that should be made available to GDCs to assist improvement

The review visited 9 commissioned adult GDCs in England:

• Gender Identity Clinic for Adults, Tavistock and Portman
• Indigo Gender Service
• Leeds Gender Identity Service
• Northamptonshire Gender Identity Clinic
• Northern Region Gender Dysphoria Service
• Sheffield Gender Identity Clinic
• The Nottingham Centre for Transgender Health
• TransPlus
• West of England Specialist Gender Identity Clinic (The Laurels)

Transcend (formerly CMAGIC, Merseyside), East of England Gender Service and Sussex Gender Service did not fall under the remit of the review, as they were not formally commissioned at the time of the visits.

Key lines of enquiry

Each adult GDC was assessed against key lines of enquiry (KLOEs) aligned to the non-surgical service specification. These were developed with stakeholders, including the GDCs, advocacy groups and the professional bodies involved in the review.

For more information, see the review methodology. 

Patient perspective

Patients’ perspectives underpin the review’s findings and recommendations. The review heard from patients during visits and through patient workshops and a national survey.

Language

The language surrounding this area is changing rapidly. Transgender, non-binary and gender diverse people describe themselves in different ways, and there is not always consensus on the best language to use.

This report tries as far as possible to use language and terms that are respectful, but that also accurately describe the complexity of what the review is trying to articulate.

In this publication, we use the term ‘transgender’ to include everyone using GDC services, whether they identify as traditional binary identities or are gender diverse people with identities including non-binary, trans-feminine, trans-masculine, genderqueer or nongender.

The language used reflects that of NHS England’s non-surgical service specification and does not indicate a position being taken by the review.

In this report, the following key definitions apply.

Gender incongruence

A marked and persistent incongruence between an individual’s experienced gender and their birth-registered sex (see World Health Organization Gender incongruence and transgender health in the ICD)

Gender dysphoria

Gender incongruence is frequently, but not universally, accompanied by the symptom of gender dysphoria. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision defines this as clinically significant distress or impairment of function.

Non-binary 

A gender identity that does not fit into the traditional gender binary of male and female.

Commissioners of services

NHS England is the current commissioner of all national specialist services, including adult gender services. The organisation that commissions these types of services will be subject to change following the abolition of NHS England; however, the recommendations will remain applicable regardless of future organisational changes.

Local commissioners

Local commissioners are integrated care boards (ICBs), which are responsible for commissioning non-specialised secondary care, primary care, community care and services from the voluntary, community and social enterprises (VCSE) sector.

National Quality Improvement Programme for Adult Gender Services

NHS England has established a National Improvement Programme, a national network for all adult GDCs and their host organisations to share best practice and learning to improve patient care and address the areas identified by this review.

Biopsychosocial assessment

The biopsychosocial assessment is a holistic framework used in healthcare that considers the biological, psychological and social factors influencing a person’s health and wellbeing to inform the collaborative formulation of patient needs and, where appropriate, develop an individualised treatment plan.

Key findings

Following the assessment against the key lines of enquiry, the review has surfaced findings around 4 core themes:

• access
• quality (including safety)
• productivity
• culture, leadership and governance

Access

A majority of these clinics have exceptionally long waiting times for NHS services, with patients often waiting for many years to be assessed. This can be distressing for patients, place undue pressure on staff and contribute to patient safety risks.

As the GDCs maintain separate waiting lists, the true size of the waiting list is unclear, as some patients may be referred to 1 or more GDC through self-referral or GP referral.

The current referral process means the majority of GDCs need to manage relationships with GPs and other services outside their region or ICB area. This places additional demands on resources.

Quality (including safety)

The absence of any patient outcomes data, alongside limited and inconsistent quality data reporting, and minimal clinical audit makes it impossible to properly understand patient outcomes and the safety of these services. These gaps place these clinics outside standard NHS quality assurance expectations.

In addition, existing patient demographic data and clinic feedback indicate that there has been a shift in patient demographics in recent years to a younger cohort with reported additional conditions. Yet, this has not always been met with corresponding changes in how some clinics identify and address patients’ potential additional biopsychosocial needs.

Productivity

There is currently a wide variation in service provision across the country.  This includes differences in the number of appointments per GDC clinician and consultation length. These variations need to be considered both in terms of improving access and ensuring high-quality services and patient safety.

Additional financial resources have been made available to each GDC to expand its staffing in recent years. However, workforce data has not always reflected an expansion in staff numbers in some GDCs.

Culture, leadership and governance

Some clinics undertake little or no quality improvement work or knowledge-sharing between services. The senior clinical leadership approach at some clinics also limits staff’s clinical curiosity and the opportunities to identify ways to improve patient outcomes. 

The review also found that oversight by some trust boards and by NHS England regional specialised commissioning teams has not consistently identified these concerns, sought any mitigating actions or supported improvements.

This contributes to concerns that these services carry a high level of risk. Commissioners and host organisation oversight, governance and supportive leadership need to be strengthened to manage this risk. This will be critical to delivering improvements.

Next steps

Based on these findings, the review panel has set out recommendations to improve patient care.

This report calls for a wider healthcare response from national and local commissioning teams, adult gender dysphoria clinics, NHS trusts, ICBs, primary care, and other healthcare constituents. This joint approach will be driven by the proposed National Quality Improvement Programme for Adult Gender Services and a new National GDC Oversight Board.

You can read these recommendations, with related commentary, in the relevant sections of this publication.

Service context

Service evolution

1. As the responsible commissioner for specialised gender services, NHS England has undertaken this review as part of a national quality improvement programme for adult gender services and to inform the new service specification.

2. The challenges have been – and remain – considerable. At its inception in 2013, NHS England inherited a fragmented configuration of 7 adult gender services that operated in isolation, with limited collaboration among them, and for which there had been no national strategic oversight. Clinical approaches varied across clinics. There was no culture of quality improvement through data collection, local or national audits or research.

3. The clinical workforce was constrained, with the gender services suffering dual problems in recruitment and retention. There was no formal entry route for training, no national professional competency framework and no approved specialty curricula in core medical training. The small clinical workforce was not prepared for the unprecedented growth in demand, the reasons for which were not well understood but reflected an international trend.

4. NHS England has acknowledged that the long waiting lists and waiting times are unacceptable. The long waits are likely to exacerbate any existing mental health problems for individuals and increase pressure on other parts of the NHS – namely primary care, mental health, sexual health and urgent care services.

5. This situation creates patient safety risks, including individuals self-sourcing hormone drugs without proper clinical oversight and monitoring, often involving high-risk places such as overseas online providers that operate outside of the jurisdiction of health and medicines regulators.

6. There has been some progress in the national commissioning approach:

• a national service specification was published in 2019
• new services have been established using a workforce from disciplines other than mental health, designed with a more integrated approach to healthcare in mind
• the Royal College of Physicians is commissioned to deliver the UK’s first accredited postgraduate training for clinicians who want to specialise in this field
• a national quality improvement (QI) network is now in place, with an external QI specialist attached to each of the gender clinics, but working as a national network to ensure consistency in approach and delivery

7. At the time of the review, NHS England commissioned 9 adult gender GDCs. 7 clinics were well-established within mental health trusts and have clearly evolved independently over time. More recently, 2 new models of provision were commissioned – a GP-led service (Indigo Gender Service) and a sexual health service-led model (TransPlus).

8. Adult GDCs are commissioned as prescribed specialised services to provide specialist assessment for gender dysphoria and non-surgical care packages. How these services should be delivered is set out in the non-surgical service specification. Service specifications are contractual documents that detail services provided and standards of care for specialised services. They are used by national and regional specialised commissioners to ensure providers meet these standards.

9. The service sees patients that identify as traditional binary identities and gender diverse people with identities including non-binary, trans-feminine, trans-masculine, genderqueer, nongender and others.

10. Access to available interventions requires a diagnosis of gender dysphoria.

Demographics

11. The service specification states:

“There is no official data on the number of people in England who present with a degree of gender variance. Difficulties in assessing prevalence are exacerbated by the limited evidence base. There is considerable variation in reported prevalence due to factors such as: variable data reporting by providers; differences in diagnostic thresholds applied and inconsistent terminology; the methodology and diagnostic classification used; and the year and country in which the studies took place.”

12. The absence of reliable prevalence data exacerbates the challenges in planning and commissioning adult gender services. What is consistent across the existing evidence is a recognition that the number of people pursuing treatment options is rising significantly.

Age

13. The adult GDCs report that there have been significant changes in the population being referred to them. The population has shifted from an older cohort to a predominantly younger age group. The majority (57%) of referrals are now 18 to 25 years old.

Table 1: Average monthly accepted patient referrals to GDCs by age group, based on a 6-month average from GDC returns

Source: Arden and GEM NHS Commissioning Support Unit data, October 2024

14. Around a quarter of these referrals are individuals between 17 and 19 years old, some of which can be explained by the transfer of patients from the children and young people’s gender service, including many that will have “aged out” (meaning they were not seen due to the long wait times). This is at least 150 patients a month (see below for forecasts). The data on the number of young people transferring to GDCs is incomplete at present due to system reporting.

15. When a young person referred to the children and young people’s gender service reaches 17 years and 9 months and is unlikely to be seen before turning 18, they receive a letter explaining that they no longer meet the service’s age criteria. The letter advises them to contact their GP if they wish to be referred to an adult gender clinic. When transferred, their position on the adult GDC waiting list reflects the time they have already waited in the children and young people’s service.

Table 2: 2025/26 monthly forecast of patient numbers who will reach adult service age threshold while waiting for children and young people’s gender services (also known as “ageing out”)

Source: Arden and GEM NHS Commissioning Support Unit data

Sex and gender

16. The GDCs have reported that the referred population has shifted from predominantly birth-registered males to a more even ratio of birth-registered females and birth-registered males. The review has not been able to obtain exact numbers, as not all GDCs report sex assigned at birth, but instead may report patient-reported gender (female, male, non-binary, other) and “not known”.

Patients’ additional diagnoses and needs

17. The GDCs have informed the review that the new, younger cohort of patients has a higher proportion of additional neurodevelopmental conditions, such as autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD), and a broader range of biopsychosocial issues, such as mental health conditions, trauma or abuse during childhood, compared to patients referred in the past.

18. This reported shift has not been systematically evidenced due to a lack of data stratifying the presenting population by additional needs and conditions; however, some GDC clinicians report that 30 to 50% of their patients may present with additional conditions.

Access

19. The review assessed GDC operation and delivery against the non-surgical service specification. The service specification (page 16) sets out the current pathway by which patients seeking support from adult GDCs can be referred, assessed for gender dysphoria and, where clinically appropriate, gain access to interventions.

20. Throughout the visits, the review examined patient flow and access, explored potential mechanisms to improve them, and considered patient needs and the GDCs requirements.

 Referrals and waiting lists

21. Although the service specification does not discuss waiting lists, the review recognises their significant impact on the operation and delivery of adult gender services. Long wait times cause delays along the patient pathway. These delays affect patient flow and limit GDCs’ ability to discharge patients and see new ones.

22. Addressing the waiting lists at each GDC is therefore fundamental to achieving improvements for patients and services.

23. Some uncertainty surrounds the true size of the waiting lists due to unknown levels of duplication; some patients may have chosen to self-refer to 1 or more GDC (they must be registered with a GP to do this) or asked their GP to do so. As the GDCs hold their own waiting lists, it is not currently possible to understand the level of duplication.

24. The waiting times for initial GDC assessment are long, and the number of patients on the waiting list is growing, with annual referrals having doubled since 2022/23. It is reported that this increase is due to more clinics reporting on the new national system and possible deferred referrals during the COVID-19 pandemic (2020-2022). Nevertheless, the issue of long and growing waiting times remains.

25. The number of patients waiting to be seen for first assessment by an NHS adult GDC rose to over 40,000 by the end of March 2025.

26. The GDCs are also impacted by the significant surgery waiting times, which for some masculinising procedures is about 8 to 9 years. This results in a considerable number of unnecessary additional GDC appointments, as the current service specification requires patients awaiting surgery to be reviewed by their GDC every 6 months.

Table 3: Reported referrals received by GDCs broken down by financial year

Source: Arden and GEM NHS Commissioning Support Unit

27. Note for table 3: Due to inconsistent or delayed reporting by some clinics and a change in the reporting system, this table may not fully capture national waiting lists. However, 2024/25 includes all referral data.

Table 4: Total number of patients waiting for first appointment broken down by financial year

Source: Arden and GEM NHS Commissioning Support Unit

28. Note for table 4: Due to inconsistent or delayed reporting by some clinics and a change in reporting system, this table may not fully capture national waiting lists.

29. NHS England has looked for ways to improve waiting times, including tendering for new services in 2019 and providing additional funding for existing services. Yet, as of October 2024, when this review conducted its visits, patients attending for a first appointment had waited an average of 296 weeks (5 years 7 months) for a first assessment. Arden and GEM Commissioning Support Unit data shows that most patients being seen during this period had first been referred in 2019.

30. At the time of the review, forecast wait times for newly referred patients had risen significantly. A majority of GDCs were projecting waits of 15 years or more if no improvements were made.

31. The distress some patients experience from long waiting times for first appointments is often exacerbated by unclear waiting times and a lack of communication.

32. Patients and staff repeatedly told the review that the long waiting times led a significant number of patients seeking a private diagnosis and hormone treatment.

33. Waiting times for these services are unacceptable. Immediate steps must be taken, and all commissioned GDCs need to work as a national network to deliver patient pathway improvements.

34. All commissioned GDCs must actively engage with the National Quality Improvement Programme for Adult Gender Services. This will enable best practice to be shared across the GDCs.

Supporting patients on waiting lists (waiting well approach)

35. In addition to the issues outlined above, long waits have further unintended consequences.

36. Mental health, physical and social issues that fall outside of the scope of the gender service are not always addressed locally while individuals are on the GDC waiting list. These conditions may require additional support upon referral, which also extends the time the individual remains under the gender service’s care. This also has a subsequent impact on the waiting list.

37. GDC staff report experiencing emotional and sometimes excessive stress when responding to patients who contact the GDC in distress, upset or angry. When this happens, GDC staff must attempt to mitigate risk for a patient they may not have seen or assessed. This can take significant time to manage, particularly for non-clinical staff members and may require intervention by a clinical lead when the concerns include vocalisation of suicidal thoughts or self-harm. This can include detailed co-ordination with external services to ensure patient safety.

38. Without support from the NHS while waiting, patients may seek information and support online and reach decisions without GDC expert input and advice. When these patients are later seen in the clinic, this can make it challenging for clinicians to provide appropriate support, particularly given concerns that some online information may be inaccurate.

39. There is potential to support and engage with patients on the waiting list, ensuring they are better prepared when they are seen by the GDC. This is known as “waiting well”.

40. The review saw some good practice in this area. For example, some GDCs publish waiting times on their websites, which can help to manage some of the anxiety created by waiting. However, it was clear that patients want personalised timelines rather than generic information or details about when current patients were originally referred.

41. In addition, some GDCs are using the VCSE sector, peer support workers and care navigators to support those on the waiting list, particularly those nearing their first appointment. This role includes signposting to regional and national support groups, as well as supporting patients in testing their chosen identity, providing advice on social transitioning, offering administrative advice about obtaining a Gender Recognition Certificate, and providing information about drug and alcohol support and domestic violence services.

42. The review found positive examples of these roles, which patients clearly value based on their feedback. However, these roles also require clear boundaries and supervision to appropriately respect and respond to individual patient choices and needs at a time when they are yet to be assessed by a clinic.

43. One GDC had created a dual peer support and administrative role, which was particularly effective in ensuring boundaries were maintained while still providing the tailored patient support.

44. Waiting well before the first assessment could include:

• broader health and wellbeing support, such as physical activity programmes, healthy weight management and smoking cessation services, which may support better outcomes for any future recommended treatments, such as hormone therapy or surgery
• referrals for appropriate diagnosis, management or treatment of other conditions, including mental health issues, neurodevelopmental conditions or speech and language support
• support for patients who are gender questioning, so they can work at their own pace to determine whether they want NHS support and what it is they are seeking from the service

45. This holistic approach to individual care could, in most circumstances, be managed at primary care level. The GDC could guide patients and their GPs to appropriate resources. This would enable patients to proactively prepare for their first assessment, supported by local ICB-commissioned services, as well as with the involvement of GDC-led peer support groups.

Initial referral and triage

46. The current service specification allows referrals from GPs, other medically qualified professionals, and other professionals regulated by the Health and Care Professions Council.

47. Individuals who present through these pathways can be referred to an adult GDC from age 17 but will not be seen until they are 18.

48. As noted previously, approximately 150 of the average 830 patients referred each month have been re-referred to adult services, having aged out from children and young people’s gender services. The breakdown between assessed and unassessed patients in the aged-out cohort is currently unknown due to inconsistent data reporting, though most patients are believed to be unassessed.

49. Patients may also self-refer to 7 of the GDCs regardless of geographical location, so long as they are registered with a GP (referrals will otherwise not be accepted). Self-referral is not standard practice for specialised services. The number of self-referrals is thought to be very small, although exact figures are unknown and could lead to duplication within the waiting list. The absence of data and standardised practice creates uncertainty about referral patterns and prevents consistent service planning.

50. For TransPlus and Indigo, the referral process differs slightly. TransPlus have been initially commissioned only to take transfers of some of the longest waiting patients from the Tavistock and Portman GDC waiting list.

51. While Indigo Gender Service does accept new referrals, service users must meet certain eligibility criteria: they must be aged 17 or over and registered with a GP in Greater Manchester and eligible for NHS treatment. Patients on other waiting lists who meet these criteria can transfer to Indigo’s waiting list. If a patient registers with a GP practice outside of Greater Manchester, either when they are on the waiting list or during their care, they will be transferred to an appropriate alternative GDC.

52. The service specification indicates that where the GP or health professional has concerns about additional conditions, patients should be referred to, assessed and treated by the appropriate local services before referral to the GDC.

53. Currently, GDCs are asked to triage patients based on the referral information to assess risk and priority before accepting eligible individuals onto the waiting list and placing them with the most suitable clinician.

54. The review found that the variable quality of referral information can add to the issue of insufficient clinic capacity, making it harder to manage growing waiting lists.

55. The service specification is not prescriptive in terms of the information required for a new referral but encourages the provision of certain standard information (as detailed in appendix B of the specification).

56. The review found that GDC administrative staff spend a considerable amount of time managing referrals. The need to contact GPs for missing information, including incomplete clinical histories for self-referred patients, delays processing and may impact effective patient triage, including the identification of potential patient safety risks.

57. When managing referrals, it was not always clear whether GPs had considered and managed any additional conditions in line with the suggested service specification approach. The review’s recommendation about waiting well highlights this finding.

58. In addition, some clinics lacked documented mechanisms to support effective triage. The review found that staff were not always suitably experienced or trained in identifying a broad range of biopsychosocial issues, potential risks or safeguarding issues and that clinical oversight was not always sufficient.

59. Other clinics demonstrated good practice in this area, including the use of checklists to support risk identification, with clear and appropriate oversight and clinical sign-off.

60. Prioritisation of referrals was limited due to long waiting times and a large number of vulnerable patients waiting. Most GDCs could no longer use any prioritisation criteria.

61. Clear standardised mechanisms for the identification of additional needs and conditions, risk and safeguarding should be established from the point at which referrals are triaged for patient safety. This will help and support patients and staff. NHS England should consider this in the development of the new service specification.

The role of primary care

62. Primary care support is critical to patients from referral, through the clinical pathway and beyond, to potentially life-long hormone prescriptions. Aside from the initial referral to the GDC, patients also rely on their GPs for the management of referrals for any other health issues and the long-term delivery of personalised care.

63. Patients and GDC clinicians report that GPs are often hesitant to prescribe hormones and monitor bloods as part of their shared care arrangement with the GDCs. The GDCs’ recommendations for prescribing and monitoring hormones are often highly complex and can run to 10 pages or more.

64. The recent Royal College of General Practitioners (RCGP) statement reiterated the important role primary care has in the provision of holistic generalist care for patients who may have gender dysphoria, from referral to life-long support for the prescribing of hormone therapy if that treatment is agreed.

65. However, the RCGP statement adds that: “GPs are expert generalists; the provision of detailed advice about gender identity issues and associated treatments does not fall within the remit of a GP’s education and training.”

66. Many GPs feel they lack the appropriate expertise to support this population. Some lack confidence due to their limited experience in this area and the complexity of prescribing. There are particular concerns about prescribing and monitoring hormone interventions, including necessary medication revisions during key life stages and illnesses, such as cancer. Some GPs feel they are being asked to prescribe off-label medications, which they perceive as creating risk. This is a longstanding issue.

67. A lack of access to primary care NHS hormone prescribing services can cause distress to patients and staff working in both primary care and the GDCs.

68. These delays waste administrative and clinical resources, as GDCs must manage relationships with numerous primary care teams while seeking successful resolutions for patients. This is further exacerbated by the need to manage relationships with GPs and other services outside the GDC’s region or ICB area, given that patients don’t need to be referred to their most local GDC.

69. The effectiveness of how GDCs manage the relationship with primary care varies across clinics. The review saw evidence of unhelpful and daunting correspondence from the clinics; there was also evidence of GDCs making significant efforts to support, train, educate and build relationships with GPs. However, many patients relied on the GDC for their hormone prescription, and GPs were instead asked to arrange monitoring blood tests.

70. The review heard that patients typically stabilise on their hormones within 1 year. GDCs have the expertise to manage this phase of care and frequently do so.

71. A new model is proposed; GDCs manage hormone prescribing for patients for a minimum of 1 year until their hormone levels are stable, then discharge those patients to a local primary care hormone prescribing service established by local or national commissioners.

72. In its statement, the Royal College of General Practitioners suggests: “exploring innovative models to provide care from local clinics supported by GPs with Extended Roles (GPwERs) with supervision from a consultant specialist in the field, where suitable for the local population.” It goes on to state that it would be “open to exploring the creation of a framework for a GPwER for care of adults in this area”.

73. NHS England, local commissioners, professional bodies and GDCs need to work together to establish how GDCs and GPs could work more effectively together, within the limits of GP competence, to provide support to patients throughout their gender services pathway and into lifetime care.

74. This is an opportunity for ICBs and NHS England to work with appropriate GP representative bodies, such as Local Medical Committees, to explore new models of primary care transgender hormone prescribing. This review does not recommend a best model; test pilots will be necessary, ideally based on ICB footprints. There are a number of options that include locally enhanced service agreements or a model of GPs with Extended Roles as described by the RCGP. The RCGP is prepared to be consulted on and engage with these models. Where clinically appropriate, non-medical prescribers could form part of the local team managing the life-long prescribing process.

75. It is anticipated that the local primary care teams responsible for hormone prescribing may differ from the practices where patients are registered.

76. The review team also heard about the development of a National Specialist Endocrine Network by the Society of Endocrinology. There is the potential that this national network of endocrinologists could support patients and GPs with Extended Roles when concerns arise. This needs to be explored by NHS England.

77. The outcome should be that each ICB has a primary care led delivery service for prescribing hormones to its transgender population, once they have been discharged from the GDC. The GDCs will then have additional clinical capacity to see and assess new patients.

78. There are already a few interested GPs who, with their primary care wider teams, could ensure local availability of hormone prescribing services for patients. This service should also include an annual follow-up appointment, as is available to other patients who are on longer-term hormone therapies.

79. The annual assessment should include the use of a national follow-up protocol with assessment of cardiovascular disease or risk as well as other any other health issues. Screening advice could also be shared with patients. There is the opportunity to collect longer-term outcome data through this process.

Referrals for surgical interventions

80. NHS England commissions genital reconstruction surgery as a specialised surgical procedure. This is covered by a separate surgical interventions service specification and is out of the scope of this review.

81. However, the non-surgical service specification clearly states that patients remain the responsibility of the GDC for referral, ongoing care during surgical waiting periods, and management before referral back to their GP. These elements, therefore, form part of the review’s remit.

82. Patients seeking genital reconstructive surgery are reviewed by their lead clinician and a similarly qualified and experienced professional to assess individual needs and readiness and to obtain informed consent before making a surgical recommendation.

83. For chest surgery, 1 surgical recommendation is required by a lead clinician. However, genital surgery patients will undergo a 2nd review with a similarly qualified professional who will provide an independent opinion on whether a recommendation and referral should be made to the National Referral Management Service.

84. Individuals with a Gender Recognition Certificate currently require only 1 recommendation for surgery from a registered medical practitioner with expertise in gender dysphoria – who knows an individual’s care plan – on the basis of informed consent.

85. Where a recommendation for surgery cannot be made, the multidisciplinary team (whose membership is outlined in the service specification) will discuss and agree a treatment plan with the patient involving either further treatment through the GDC or discharge to their GP (6 months after the final intervention).

86. Post surgery, patients are discharged back to the GDC and remain under the clinic’s care until at least 6 months after their final intervention.

87. It is important to note that genital surgery for transgender patients can be very complicated. For some surgeries, there are typically 3 to 4 procedures over many months.

88. The review found that the average waiting times for some surgical procedures are long:

• chest surgery – 2 to 4 years
• genital surgery – 5 years wait for an outpatient assessment and a total wait of around 8 to 9 years, sometimes longer

89. Patients and GDC staff commented on the impact of the long waits for genital surgery.

90. While some patients had a positive experience of the referral process and felt they received good-quality care, for many, the wait was a challenging experience, and patients felt more information could have been shared about the status of their referral.

91. These waits also impacted GDC capacity, as patients awaiting surgery as part of their treatment pathway need to be seen every 6 months according to the service specification. Nationally, this amounts to approximately 300 follow-up appointments each month. This has a considerable impact on patient flow, limiting the capacity for first and second appointments and can be considered unnecessary by both patients and GDC staff.

92. Several of the GDCs have introduced, or are looking to introduce, a patient initiated follow up (PIFU) to reduce unnecessary clinic visits for patients awaiting surgery.

93. Despite the current requirement for an annual review for patients awaiting surgery by the GDCs, the review heard of incidents where patients arrived for surgical procedures or consultations inadequately prepared for surgery. This included not having correct hormone levels, not completing the recommended weight loss or smoking cessation, as well as lacking the necessary support for recovery and time off work. Some of these incidents resulted in delays to surgical procedures, with cancellations of valuable theatre capacity. In part, this may be due to the very long surgery waits, followed by the sudden notification of a surgery date.

94. Gender specialist surgeons also highlighted the need for psychological support for patients within 6 months of surgery, and consideration should be given to how a psychology service can be part of the core surgical team.

95. The review heard from stakeholder groups that they felt the use of Body Mass Index as a measureas unhelpful and shaming. However, specialist surgeons have advised that for some genital surgeries, the risks of complications and procedure failure are closely related to this measure.

96. The waits are so long for surgical assessment and for surgery that some patients may have differing biopsychosocial characteristics by the time they come to surgery.

97. NHS England needs to look at a new approach to mitigate the very long waiting times. This approach should include a further assessment process, including psychological, social and surgical assessment, that is undertaken nearer the time of surgery with clear communication about wait times.

Detransition

98. The review heard that, following assessment and treatment, some patients express regret or dissatisfaction; a smaller number choose to discontinue or reverse their gender transition. Some later decide to retransition.

99. The number of patients who express some form of regret, dissatisfaction or choose to detransition is unknown due to the absence of GDC outcomes data.

100. The patient survey summary report stated: “Participants who had experienced a change in their transition goals, those who decided to pause transition, or those who had decided to detransition temporarily or permanently, had mixed views on the support provided by their clinic. Some patients felt they had not been supported by their clinic (for example, the clinic had not contacted them), while others felt their clinic respected their decisions and supported them, for example, by sharing information or offering counselling.”

101. The GDC’s clinicians shared that patients process and express their feelings in different ways; some wish to fully detransition, while others have oscillated or wavered in their resolve to transition, or have stopped medical or surgical transition without returning to their birth-registered sex. Some choose to continue living in their transitioned gender, given the potential physical, mental and social complexities of detransition.

102. The review has been informed NHS England is beginning to develop a pathway for this cohort.

Forensic provision

103. Forensic transgender care is a highly specialised area of gender activity that involves assessing and treating individuals who have been involved in criminal activity or who may pose a risk to the public. This may include those patients detained in a prison or a secure hospital setting.

104. While the service specification sets out the requirement for each provider’s multidisciplinary team to have access to expertise in forensic psychiatry or forensic psychology (along with the competency to recommend reasonable adjustment in gender-related treatment planning for affected individuals), delivery of a forensic gender dysphoria service for these patients is not a requirement within the service specification.

105. As part of the referral information, referrers are also encouraged – although not required – to include any forensic history a patient may have.

106. Currently, 3 clinics undertake assessments for individuals in prisons or forensic settings under existing specialised commissioning contracts; referrals to other clinics will be transferred to 1 of these 3 services. No additional funding is provided for this cohort of patients on top of the existing allocation received from NHS England.

107. The review has heard that senior clinicians undertake this work due to their special  interest or expertise in this area. Travel to secure settings, where patients are often located, can be time-consuming, often taking clinicians away from clinics for days at a time to see a single patient. Where secure GDC facilities exist, forensic patients may be brought there instead. The review was told that challenges can arise around the availability of clinical records and information, sometimes resulting in clinicians being unable to fully assess these patients.

108. This forensic GDC activity is not reported separately and instead forms part of the overall GDC appointment figures submitted. As a result, the review was unable to fully understand how many forensic patients were being seen or the outcomes from their assessment and treatment.

109. Although conversations with clinicians indicated forensic patient numbers are small, assessing and treating these patients has a significant impact on clinical resources, removing senior or lead clinicians from clinics for long periods of time. This is not a good use of limited clinical resources.

Estates and location

110. The current service specification requires providers to have premises that are appropriate to ensure the effective delivery of the services. This should be in an environment that service users regard as safe and welcoming.

111. The estate in which NHS GDCs currently operate is variable. Several clinics are located within city centres, often within areas known for strong LGBTQ+ communities and support services, which many patients viewed positively. Others are set within more traditional clinical sites, such as mental health and community hospitals. In response to the review’s patient survey, 87% of respondents stated the location of their clinic was either very suitable or suitable.

112. The review is aware of the wider challenges related to the NHS estate and recognises that it is not necessarily easy or practical for services to find or relocate to new premises. On that basis, it is important to consider where clinics, and the trusts or organisations they sit within, could make improvements to their current sites.

113. Signage to some of the GDCs was poor and, at times, made them challenging to locate. Although the review heard that some patients valued discreet settings, there is a balance to be found with ensuring services remain visible and accessible to patients.

114. The review saw an example from 1 clinic of a helpful video that patients could watch in advance, which showed what to expect from a face-to-face appointment, including where they would enter the building and be greeted.

115. Given that adult gender dysphoria services are not mental health services, it is particularly important that where these services are co-located, they are clearly and easily differentiated. The review noted this issue was particularly pronounced where waiting rooms were shared with mental health services. Wherever possible, adult GDCs should have their own waiting spaces or rooms to help patients feel as comfortable as possible.

116. Accessibility is also an important consideration. The review heard from some patients that certain clinics had poor access into and around the building and should be more disability friendly.

117. Several clinics had made considerable efforts to ensure clinical and waiting spaces were suitable and supportive for neurodiverse patients accessing the services.

118. Patients also raised travel and access to each clinic. While some may have chosen to travel further to access a specific clinic, the current geographical spread means some patients have to travel a significant distance to attend face-to-face appointments at their GDC.

119. The review found significant variability in public transport access and car parking across clinics. The review saw examples of patient information to mitigate against this, setting out clear travel and access instructions. All GDCs should implement this approach. Patients should also be made aware that financial support is available to those in receipt of certain benefits to enable them to attend appointments.

120. Consideration needs to be given to the geographic spread of the GDCs. The existing services have mainly grown independently.

121. Including the pilot sites, there is at least 1 adult GDC in each NHS region. However, there are significant gaps in the West Midlands and around the Bristol area. These areas should be prioritised where possible for any future service expansion. The co-location with regional children and young people’s gender services within a city should also be a priority to support and facilitate optimal transition of patients from one service to another. This could be achieved by sharing staff, data and research projects.

Quality (including safety)

Assessment  

Current assessment requirements 

122. The non-surgical service specification requires GDCs to provide a minimum of 2 assessments; at least 1 of the consultations should be face-to-face. 

123. Assessment 1 – An assessment for gender dysphoria is conducted by a regulated health professional (or a supervised trainee). Information is collected about the individual’s objectives for their engagement with the service; their gender identity and expression (current and historic); and basic biopsychosocial history. This should also include the provision of information, for example, support agencies and lifestyle information, such as weight and smoking and drug habits.

124. Assessment 2 – This consultation is conducted by a medical practitioner or clinical or counselling psychologist (or by a supervised trainee). Information from the referrer and the initial consultation, together with any investigation results, is reviewed and further explored with the individual. Diagnostic coding is discussed and agreed with the individual. The individual’s treatment goals are discussed and agreed. A general assessment of capacity to consent to treatment is made.

125. A registered medical practitioner or clinical or counselling psychologist is appointed as lead clinician for patients who progress to a planned intervention on the NHS care pathway. The lead clinician provides oversight of each patient’s progress toward completing their treatment plan.

126. A “named professional’ is also appointed. This is a regulated health professional who will act as the individual’s primary “point of contact” with the service, provide basic information about interventions and the care process, and oversee and facilitate timely progress through the individual’s treatment plan, including those elements of the care pathway that are delivered by other providers.

127. The GDC named professional and lead clinician will provide individuals with the necessary information about all of the options available to them so that they may ask questions, explore the available options, and take an active role in determining a treatment route which best suits their needs and preferences and is clinically appropriate.

128. The GDC named professional and lead clinician must make all efforts to ensure that individuals are aware of the longer-term consequences of the offered interventions. The consequences of treatment decisions can be significant and life-changing.

129. A written treatment plan, with indicative timelines, is then discussed and agreed with the individual and shared with the GP. This may include hormone interventions, psychological therapy, speech and language therapy or epilation (facial hair reduction).

130. Other possible outcomes include recommending to the GP (or other referrer) that the individual is also referred to other services, or that a referral should be deferred to a later date because of other health or social issues that would prevent the individual from currently benefiting from interventions. All outcomes should be clearly explained to the individual.

131. Some patients have complex or additional needs. In these cases, more than 2 core assessment consultations may be appropriate. This may include people with co-existing complex physical or mental health problems, communication difficulties or learning difficulties. In these circumstances, the clinician is required to explain to the individual the reason for the proposed additional consultations.

132. The specification recommends that complex cases require further assessment and discussion at the GDC multidisciplinary team meeting. The membership of the GDC multidisciplinary team is clearly described in the service specification, reflecting the mix of required skills, experience and expertise.

133. Should gender dysphoria be diagnosed following this further assessment, a treatment plan should be discussed and agreed with the multidisciplinary team and the patient. 

134. It is through the assessment process that GDC clinicians determine whether gender dysphoria is present and, therefore, whether suitable treatment and interventions can be recommended.  

135. The review saw considerable variation in the approach taken to the assessment process, including the: 

• clinical profession of those undertaking assessment elements
• assessment format (time, location and areas covered) 
• approach to the changing patient population and managing complexity
• approach to and use of the multidisciplinary team meeting
• approach to informed consent 

Clinical profession of those undertaking assessment elements

136. The professions used to undertake the assessments vary based on GDC staff composition. Some clinics use lead clinicians to conduct the first assessment. At some GDCs, this role will be held by psychiatrists or clinical psychologists, while at others, this may be the role of a general practitioner specialising in gender care. Other staff groups, such as nurses and physician associates, may also be used to take the patient history, with oversight and supervision provided by a senior clinical team member.  

137. Concerns have been raised with the review that, on occasion, any additional needs or conditions could have been identified and supported sooner, had those staff undertaking the assessment been suitably qualified, competent, skilled and experienced.

138. Identification of biopsychosocial issues can be challenging. The review has heard from both clinicians and patients that some patients may choose not to share information during the assessment period due to fear that this may prevent or delay them achieving their transition goals (a fear compounded by the long waits).

139. While it is the responsibility of the patient and their GP to provide the GDC with the necessary information to support the best care, it is also important that those undertaking the assessment are appropriately trained to ensure the patient receives the right support as early as possible in the pathway.  

140. First assessments should be conducted by a senior clinician in a face-to-face meeting. This could be a clinical psychologist or psychiatrist, particularly as there are a range of additional conditions within the presenting population that would benefit from this expertise to ensure any broader needs are identified and supported.

141. Patients should be seen by 2 different clinicians during the assessment process at a minimum, to ensure patients benefit from the GDC clinical teams’ expertise and to confirm the clinical diagnosis. 

Assessment format

142. The time taken to conduct each assessment varied from clinic to clinic, ranging from an hour to more than 2.5 hours when including the time required to draft clinic notes and letters.  

143. There was also a variation in the use of face-to-face versus online appointments, with some clinicians and patients noting a resistance to face-to-face contacts among some patients. Younger patients were often reported to prefer online interaction due to travel logistics. This is particularly relevant, as other than Indigo, GDCs accept referrals from across England.

144. Many clinicians emphasised the importance of face-to-face appointments, particularly for the initial assessment. This allows a better insight into how the patient is functioning in their day-to-day life and helps clinicians understand any potential wider needs and additional conditions.

145. Sufficient time needs to be allocated to ensure that each patient receives a comprehensive biopsychosocial assessment and any additional conditions or safeguarding issues are identified. However, the review found some clinics were using the assessment to undertake other activities that could be delivered more efficiently in other ways, thus freeing up clinician time. Other clinics demonstrated good practice, using other GDC staff groups to:

• gather basic patient information in advance of any assessment, allowing assessments to focus on gender dysphoria   
• provide information on sources of support and lifestyle information
• undertake a basic physical examination only (height, weight and blood pressure)

146. Extended physical examinations are not a requirement of the service specification and should stop. These are not a beneficial use of GDC staff time, and where the GDC clinician or patient has any concerns, they should be referred to the patient’s GP.

Approach to the changing patient population and managing complexity

147. As outlined in the , GDCs have reported that the referred patients are moving towards a younger population with a more even ratio of birth-registered males and birth-registered females. This cohort has also been reported as having more complex physical, social and mental health needs. There is no data to support this.

148. Neurodevelopmental conditions do not indicate complexity, although patients with these conditions may require considerations about processing and language, physical sensitivities and increased susceptibility to trauma and mental health conditions. The review heard that some GDC staff had adapted their practice and the clinic environment to support these patients.

149. Each GDC has responded to this change in the presenting population differently. Some have responded by developing checklists to ensure that additional areas are covered during the biopsychosocial assessment process. Other GDCs have been less responsive.

150. Some patients told the review that they see the biopsychosocial assessment as intrusive and running contrary to self-determination. However, GDC clinicians consider comprehensive biopsychosocial assessment essential to understanding patients’ needs and any additional conditions; it ensures patients are prepared for transition and helps identify support for longer-term resilience, thereby optimising patients’ outcomes.   

151. Although each GDC has identified the areas that need to be covered as part of the assessment process, there is no national standard framework or agreed approach to undertaking the assessments. A national comprehensive biopsychosocial assessment framework should be developed to ensure each patient’s needs are identified, formulated and interventions are agreed, regardless of which GDC they attend.

152. Staff undertaking the assessments will require the appropriate professional background and training to ensure they possess the necessary competencies to apply the framework effectively.

153. One GDC has developed a complexity measure, which supports understanding of the impact of any additional conditions and helps identify patient needs and required support. The complexity measure can inform decisions about whether a multidisciplinary team discussion would be appropriate and beneficial for that patient.

154. This measure is now being shared across a number of GDCs. Adoption of this complexity measure nationally would require some additional GDC staff training.

155. Biopsychosocial and complexity assessment should lead to a holistic, individualised formulation for each patient. This formulation should include an understanding of how gender dysphoria has arisen; complexity assessment should not simply be confined to the identification of additional conditions.

156. Where significant additional health needs are identified through the biopsychosocial assessment process, it is generally recommended for patients to have extra assessment sessions based on their individual circumstances. These sessions may be with a psychologist or psychiatrist. However, this varies across the GDCs, and patients are not required to use these services.  

157. Using a national biopsychosocial framework and a national complexity measure together will enable standardisation and delivery of a high-quality assessment approach. It will also help identify patient subgroups and their outcomes, as well as inform future national audits.

158. This approach will also support newer GDCs in identifying which patients with additional needs should be referred to other GDCs with the appropriate in-house expertise.

159. To maximise the potential of these national tools, investment will be needed in: 

• training staff across all groups to ensure they are competent in using the measures effectively
• integrating these tools into digital pathways to support patient outcome auditing 

Gender Recognition Certificate

160. At times, GDC clinicians highlighted the challenges of undertaking assessments where an individual has already received a Gender Recognition Certificate (GRC), as these patients may consider the certificate as exempting them from any extensive assessment.

161. The service specification advises: “Possession of a Gender Recognition Certificate (GRC) does not in itself provide the multidisciplinary team with the clinical information that is necessary to assess an individual’s suitability and readiness for medical and other interventions. Therefore, individuals holding a GRC still need to be assessed by a GDC for readiness of interventions.”

Use of the multidisciplinary team

162. Multidisciplinary teams are used across the NHS and are a key part of many diagnostic and treatment pathways. They bring together professionals from different disciplines – with a mix of skills, experience and expertise – to make more informed decisions about an individual’s treatment and care and to deliver better outcomes, particularly for patients with complex needs. They meet regularly to discuss patient cases, review treatment plans and ensure co-ordinated, integrated care. 

163. The GDC multidisciplinary team meeting is important for providing clinicians with the opportunity to openly discuss individual cases where additional insight may be helpful. This helps ensure the best care for individual patients.

164. The review found that the use of the multidisciplinary team to consider individual patients’ needs varied considerably between GDCs.

165. Documentation of the multidisciplinary team process was not always clear, particularly regarding how patients were selected for discussion and how decisions or governance was recorded.

166. This process documentation needs to be improved to ensure all GDC staff are clear on the multidisciplinary team’s purpose.

167. GDC staff should be able to bring all cases to the multidisciplinary meeting where there is concern, or where they feel the patient may benefit from a broader discussion. There may be instances where additional information results in a patient’s case returning for further consideration by the multidisciplinary team.

168. The frequency of meetings should be sufficient to allow all identified cases to be adequately discussed. The culture within the GDC should support all multidisciplinary team attendees in offering their opinions freely.

169. Peer-to-peer discussions and supervision are also important in supporting staff to identify the best clinical approach. However, complex cases should always be brought to the multidisciplinary team. There should be clear governance mechanisms in place, and the decision of the multidisciplinary team should be recorded in the meeting minutes and in the patient’s record.

170. Multidisciplinary team meetings are important in developing an understanding of the patient cohort and their treatment. They also enable more junior staff to understand how concerns are identified and what may trigger escalation, as well as how treatment decisions are reached. All clinical staff should have the opportunity to attend and hear multidisciplinary team meeting discussions where appropriate.

171. The weight given to the multidisciplinary team meeting discussion also differed across the GDCs. Many GDCs viewed the decisions made by the multidisciplinary team as a strong recommendation, while others considered any outcomes to be advisory. Any recommendation from the meeting carries significant weight and authority. In instances where the treatment proposed by a clinician differs from that agreed at the multidisciplinary team meeting, the case should be brought back to a future meeting for further discussion before commencing treatment. 

172. The review of the service specification should be clear about the management of multidisciplinary team meetings, patient selection, recording of decisions and governance.

Informed consent

173. GDC named professionals and lead clinicians are required to make a general assessment of any individual’s capacity to consent and must follow the requirements of the Mental Capacity Act 2005 as part of the diagnostic assessment and treatment planning consultation. 

174. In the NHS, all adults are assumed to have sufficient capacity to make decisions about their own medical treatment, unless there is significant evidence to suggest otherwise. This capacity can change over time and can be temporarily affected. If someone does not have capacity, another person can make the decision on their behalf, provided this is deemed to be in their best interests. The giving of consent should then be appropriately documented.

175. As a clinician’s assessment of an individual’s capacity to consent is an ongoing process – integrated into every patient interaction and supported by both written and verbal information – the review was unable to fully explore the consent process. However, the quality of the written documentation provided varied.

176. Clinicians should identify any concerns surrounding the ability to consent through cognitive assessment as part of the biopsychosocial assessment and be cognisant of the impact of any additional conditions, such as a learning difficulty or an acquired brain injury.

Other gender dysphoria clinic services

177. GDCs should enable access to a number of other services (interventions), where agreed with the patient’s lead clinician, to support an individual’s transition in line with their identity goals. The following are provided directly by the GDCs:

• voice and communication therapy
• specialised psychological interventions
• assessment for endocrine and other pharmacological interventions

178. Services can be accessed concurrently or sequentially, depending on patient requirements. On completion, patients are referred back to their lead clinician and remain with the GDC until at least six months after the last intervention.

Voice and communication therapy

179. Voice and communication therapy aims to facilitate changes in an individual’s voice and communication style, helping to alleviate distress related to gender dysphoria and improve quality of life.

180. Under the current service specification, patients are given access to specialist voice and communication therapy based on clinical need and individual choice, with the number and frequency of sessions dependent on individual needs. This may be provided through individual or group therapy sessions. Some GDCs had an upper limit to the number of sessions due to internal waiting times.

181. In less complex cases, the GDC may refer an individual to a local speech and language service (commissioned by the individual’s ICB), with support from the GDC.

182. The review saw good practice in relation to speech and language therapy across many of the GDCs. This included a strong national, cross-clinic approach for sharing learning and ideas, as well as providing mentoring and support. At some clinics, innovative practice, such as group singing workshops, had been implemented and received positively by patients.

Specialised psychological interventions

183. Patients should be given access to specific psychological interventions tailored to their individual needs, based on psychological assessment and collaborative formulation. These interventions are not offered routinely or considered mandatory but are made available with the patient’s consent and focused on specific psychological needs.

184. There was considerable variation in access and provision of psychological support across the GDCs. Patients were positive about the psychological support services and their benefits, where available, but patients highlighted long internal GDC waiting times.

185. In many GDCs, if a patient is found to have significant complexities following their biopsychosocial assessment, they are discussed by the multidisciplinary team, which may recommend further assessments, including psychological assessment and support.

186. Each GDC should ensure they have appointed or have access to a consultant clinical psychologist to support patient care.

Assessment for pharmacological interventions

187. Under the service specification, clinicians are required to assess an individual’s suitability for hormone treatments for the alleviation of gender dysphoria and in achieving gender expression congruent with their identity and consistent with their treatment goals.

188. A registered medical practitioner in the specialist multidisciplinary team may then recommend endocrine and other pharmacological interventions, following which the GDC will request the patient’s written consent (a copy of which is shared with the individual and their GP).

189. GDCs are expected to provide GPs with patient-specific “prescribing guidance” to enable them to appropriately support their patient, including:

• a written treatment recommendation
• detailed information about necessary pre-treatment assessments
• recommended preparations of medications
• advice on dosages
• administration, initiation and duration of treatment
• physical and laboratory monitoring
• interpretation of laboratory results
• likely treatment effects

190. They are also expected to provide advice to GPs when requested.

191. Alternatively, the GDC medical practitioner may decide to assume responsibility for prescribing for a time-limited period that is appropriate to the individual, before transferring clinical responsibility to the individual’s GP.

192. The review has heard from many patients and staff about the challenge facing the GDCs and their patients in the absence of a national agreement with primary care services to monitor and prescribe hormones. This is described further in the section on the role of primary care.

External services

193 The GDC may recommend to the GP that they refer the patient to other services as appropriate and with the patient’s consent, including:

• fertility services for gamete storage
• epilation (facial hair reduction)

194. The review saw evidence of fertility information provided to patients. However, eligibility for gamete storage is determined on a case-by-case basis by the patient’s local ICB, which caused concern for some patients.

195. It is important that all patients understand the implications of interventions on their fertility and have the choice to defer treatment, as needed, to ensure that opportunities to preserve fertility options can be met.

196. Many patients commented that staff explained the treatment options clearly and detailed the risks and benefits of each treatment, and that they allowed patients to make their own decisions without rushing them.

197. Patients frequently raised the issue of epilation which is covered as part of current service specification.. Some patients expressed a wish for further funded sessions and to have the choice of their own provider. This would need to be considered alongside other NHS funding priorities.

Data, audit and research

198. The service specification sets out clear standards for GDCs to meet with regard to collecting and using data, collecting and reporting specialist commissioning quality data, participating in local and national audits, and conducting research to help evaluate effectiveness and drive service improvement.

199. The doctor’s role in this area of quality assurance and quality improvement is underscored by the General Medical Council’s Good medical practice guidance.

200. Adult gender services is an area where, despite considerable interest, little is known about the characteristics of the presenting population, the impact of individual interventions or patients’ longer-term health outcomes.

201. The review found that very little data is collected or shared by the GDCs, other than the waiting time and the GDC activity dataset. This is despite the expectations set out in the service specification for each GDC to participate in local and national audits and share the outputs in an annual report to the commissioners.

202. Similarly, there is a requirement for all commissioned GDCs to submit data for specialised service quality dashboards (SSQD) to enable commissioners at the regional and national level to understand and track quality outcomes for GDC patients.

203. The review found that very little data is actually submitted against these measures. There is no quality outcome measure for which more than 4 clinics have provided a response, and some GDCs submit no SSQD data at all.

204. Clinical audit is critical to understanding the presenting population, changes in outcomes within individual GDCs, between GDCs, and over time, as well as improving the quality-of-service provision. National audits also support the generation of research questions, which will inform and improve the quality of adult gender dysphoria services in the future.

205. The review found that while some GDC staff were intellectually curious, internal audits were not always uniformly encouraged. There also appeared to be little sharing of any local audit findings across the GDCs.

206. Clinicians raised the challenges of undertaking clinical audits on a population that may feel vulnerable and mistrustful about how data is held and used. However, the lack of data and audit is currently placing this patient population at a significant disadvantage when compared to other NHS patient populations. This perpetuates the inequity in healthcare provision for the transgender population.

207. As stated in Professor Alice Sullivan’s recent review of data, statistics and research on sex and gender, particular care should be taken when collecting data on gender reassignment or trans status due to its sensitivity and the small population size. Organisations should only collect data which they intend to process, and consideration needs to be given to whether data collection is appropriate based on several factors, including:

• the size of the dataset
• the proposed use of the data

208. In this instance, however, the population size means that with appropriate steps, commonly used in many other national audits, patient anonymity can be protected in line with Caldicott guidelines. The benefits for patients of this data collection and resulting research would be huge.

Existing outcomes data

209. Since 2021, NHS England has commissioned the Arden and Gem Commissioning Support Unit to collect data from each GDC on the numbers of patients waiting, waiting times, clinical activity within the GDC and workforce numbers.

210. There are challenges in interpreting this information due to some GDCs not reporting to the monthly deadline. Although data reported after the deadline is corrected the month after, this can impact the ability to understand the true national position in real time. Furthermore, some trusts’ systems cannot report data at an appropriate level of detail.

211. There is no robust data on treatment and outcomes other than the reasons patients are discharged from the GDCs.

Table 5: Reasons for GDC discharge (excluding patients transferring between clinics) based on a 6-month period

Source: Arden and GEM NHS Commissioning Support Unit GDC monthly activity return, October 2024

212. There is variation between GDCs, and some patients reported being abruptly discharged from clinics.

213. That only 31.5% of patients are discharged having completed their treatment raises questions about why patients are discharged and why patients do not attend or cannot be contacted. This should be an early priority for a national audit.

214. There is a clear national expectation within the service specification and from NHS professional regulators that GDC clinicians should be undertaking data-driven reviews of the safety and outcomes of their work.

215. It is unacceptable that there is no outcomes data to support or guide patients, clinicians, and commissioners in understanding which treatments and interventions may deliver the best outcomes for patients.

216. NHS England should work with the GDCs to develop a national minimum dataset to include treatment and outcomes data from each commissioned GDC. This minimum dataset will also need to include and record patients’ birth registered sex.

217. There should be an expectation that all commissioned GDCs actively and fully participate in a national GDC audit programme, with support from NHS England and senior board leaders from their host trusts or organisations. This should be monitored by NHS England and trust and organisation boards through quarterly reports in the first instance.

218. This will facilitate the development and delivery of national audits to understand any variation in outcomes between clinics and give GDC staff and patients confidence that high-quality care is being delivered. By participating, patients and the GDCs will contribute to better evidence-based care for all future patients.

219. The development of the dataset would be supported by the standardised approach to a comprehensive biopsychosocial assessment and the consistent use of a complexity measure by all GDCs. This will enable the identification of patient subgroups and a more precise analysis of the differences in outcomes for these groups.

220. The prescription of hormones for transgender patients is a lifelong process. The review has already recommended the development of local hormone prescribing services managed by primary care teams. Consideration should be given to obtaining primary care data, which when linked, would enable analysis over a longer timeframe. Access to this data can bring a better understanding of cardiovascular health and other possible increased health risks for transgender patients.

221. A broader issue concerning NHS number changes was raised with the review. NHS guidance currently requires changing an individual’s unique NHS number when their gender is changed on their NHS record. This has implications for healthcare professionals’ ability to appropriately support the broad healthcare needs of transgender patients due to the potential loss of clinical information. It also affects the management of risk and long-term health needs (such as screening) and impacts understanding of longer-term health outcomes for this population.

222. While this review was taking place, the Sullivan Review (2025) recommended that the NHS number should not be changed after transition. It is beyond the remit of this review to take a position on this finding. It is important that its implications are sensitively worked through with the transgender population.

Engaging in research

223. These services need robust, high-quality research. While the review heard that some GDCs were involved in national or international research projects, little evidence was shared before or during the review visits.

224. NHS England should work with the GDCs – through the National Quality Improvement Programme for Adult Gender Services – to determine how they can collaborate to develop a national adult research strategy for gender dysphoria services.

225. Patients should have opportunities to meaningfully engage in this important area of work and enter into well-designed studies to determine their best possible care.

Understanding and meeting the patient needs

226. The review was asked to consider how the current service model meets the needs of patients across the pathway. Consideration of these needs underpins the review recommendations, which, when taken together, will improve patient flow and care provision.

Patient perspective

227. It was important for the review to understand from transgender patients their experience of accessing GDC services.

228. Most patients reported that once they had been seen by the GDC their experience of the service and the care provided was generally positive. Main patient concerns related to:

• long waiting times
• the need for better communication, particularly while on the waiting list, and for the accommodation of different communication preferences
• the need for an increase in both service provision and trained staff to meet the demand for services and for that provision to support access closer to home
• challenges in accessing support from primary care for blood monitoring and hormone interventions, with the need for GDCs provide access and to work more closely with GPs for a more joined-up approach

229. In most cases, patients were positive about their interactions with GDC staff and felt listened to and understood. However, some patients expressed concerns around interactions that had left them feeling uncomfortable or dismissed and reported power imbalances between patients and staff. This report has set out the need for a compassionate, safe and positive culture within all GDCs.

230. A summary of what the review heard is at [Report to be published on Arden and GEM website].

GDC perspective

231. GDC staff were aware of and, in many cases, were acting upon the patient concerns set out above.

232. Some GDC staff described instances where they have been accused of transphobia or gatekeeping when adhering to professional clinical standards or offering services that are within the service specification.

233. Both GDC staff and patients have an important role in creating a respectful and compassionate culture. It is important that patients understand that GDC staff are working to specific protocols, processes and professional standards designed to achieve optimal patient outcomes.

Productivity

Finance

234. The National Specialised Commissioning team have responded to an increase in patient referrals and longer waiting times in the last few years with additional investment in the GDCs.

Table 6: Summary of annual spend for adult non-surgical gender services: 2020/21 to 2024/25

Source: NHS England Specialised Commissioning

235. Some of this investment has enabled 5 new pilot GDCs to open, 2 of which had already been formally commissioned at the time of the review and were visited.

236. Additional funding was given to the 7 existing GDCs, with the expectation that staff numbers and, consequently, capacity would increase.

237. Funding for the GDCs is allocated via block contracts. Block contracts are paid directly to the host trust or organisation, which allocates funding to the clinic. Block contracts do not reward additional activity; the amount of funding received is not dependent on the number of patients seen.

238. The majority of GDCs also make a payment to their host trust or organisation for overheads, including the provision of corporate services, such as staff training, HR support and ground rent. This is normal practice for services provided within the NHS estate.

239. The NHS trust is accountable to the relevant NHS England regional specialised commissioning team for management of the service. The regional specialised commissioning team is responsible for setting activity levels for the funding received and monitoring the outcomes for the allocated funding.

240. However, the NHS trust or organisation also has responsibility for managing funding and achieving financial balance across a broad range of services. As a consequence, local trust decisions may be made in terms of how the total funding allocation can be best utilised.

241. Although additional funding has been allocated to support an increase in capacity, a number of clinical vacancies remain unfilled across the GDCs. Some GDCs have had little or no increase in their clinical workforce between July 2023 (when reporting of GDC clinical workforce began) and December 2024. Although there are issues with recruitment into these services, anecdotally, the review has heard that some trust or host organisations have restricted recruitment.

Table 7: The GDC staffing position Quarter 4 2024 to 2025

Source: Arden and GEM Commissioning Support Unit

242. It is clear that some GDCs are either unable to fill posts or are holding posts vacant for other reasons.

243. NHS England should consider the development of a new model of funding for GDC services that incentivises increased capacity and reductions in the waiting list.

244. Commissioners need to be assured of the rationale for overhead costs and vacant posts.

Workforce and training

Recruitment and retention

245. The service specification states that each adult GDC requires:

• a senior clinical lead who must demonstrate evidence of appropriate experience and expertise in specialised gender dysphoria practice; significant management experience; and significant evidence of continued professional development
• a specialist multidisciplinary team of professionals, with a mix of skills, experience and expertise that is appropriate to ensure the delivery of effective and high-quality services in accordance with the requirements of this service specification
• sufficient administrative and managerial support for efficient and timely delivery of services

246. This review has already raised concerns that some GDCs have not always had support from their host trusts to fill or increase posts, despite rising waiting lists, longer waiting times and additional funding from commissioners.

247. Each GDC highlighted challenges in relation to recruitment and retention as part of the review.

248. The GDCs noted these services draw significant public, media and political attention, with polarised views, which can make working within these services appear less attractive. However, the review also met many staff who had been attracted to work at the GDCs either through work experience or having been a past patient.

249. Some GDCs had taken significant steps to rectify their recruitment challenges by offering staff flexible working and allocated career development time.

Training

250. The service specification states that the Gender Identity Healthcare Credential – developed by the Royal College of Physicians (RCP) – is for statutorily regulated healthcare professionals from any relevant profession who work with adults who may need gender identity healthcare. It asks each GDC to make arrangements to support GDC professionals in undertaking the programmes of study, which include a mix of work-based supervision and assessment.

251. There are 3 professional certificates used to train staff. The certificate in core capabilities in clinical practice for adult gender identity healthcare is a prerequisite to completing certificates in advanced capabilities and prescribing capabilities. Staff will complete the certificates as appropriate to their role and profession. Established GDC staff, with the appropriate expertise, have been assessed and awarded accreditation via a “grandparenting” route (this route is no longer open to new applications).

252. The programme content was developed through an extensive process of stakeholder consultation, including input from various Colleges and professions, as well as people with lived experience. Programme development was initially scoped by the RCP’s Executive Director of Education, working with the chair of NHS England’s Task and Finish Group for Gender Dysphoria and the chair of NHS England’s Clinical Reference Group. There is a faculty of experienced professional educators.

253. In view of some patients having additional conditions and complex presentations and the need for a whole-system approach to resolving the current position, it is recommended that the RCP work with other relevant royal colleges (such as the Royal College of General Practitioners and Royal College of Psychiatrists and relevant associations) to further develop the training offer to reflect the additional needs of patients.

254. An improvement to the certification process could be requiring trainees to spend some time, even just a day, at another GDC to see how they approach common issues. A noticeable element of this review process was how much the peer review component was valued by GDC staff visiting another GDC, with several asking whether examples of good practice could be shared more widely. While supervisors often encourage the observation of experienced clinicians, this could be formalised.

255. The certificates complement professional qualifications by evidencing the relevant capabilities in practice to deliver adult gender identity healthcare. They were developed to provide consistent standards in areas of practice where concerns about patient safety may arise due to gaps in training or service, where vulnerable patients are at risk, and to meet future service needs.

256. GDCs are also required to ensure that staff in public-facing roles receive ongoing training and have arrangements in place to be sensitive to the potential health and social care needs of transgender patients. The review heard the majority of GDC staff were culturally competent and cognisant of the challenges faced by their patient population. However, some staff indicated that they would appreciate further training in this area, and patients highlighted the importance of having a workforce that understood their broader needs.

257. The review found that many GDCs had policies and procedures for staff training and had identified the required competencies. While there was evidence within some staff job plans that time had been allocated for training and professional development. It is important that all GDCs view this as a priority.

Collaboration and a networked approach

258. GDCs also have wider responsibilities in relation to training, including the provision of support, advice, expertise and training for the local, regional and national networks.

259. The review saw emerging examples of collaboration, engagement, peer review and sharing of good practice across the GDCs. This was evident in areas such as the development of the complexity measure and sharing expertise through shadowing, supervision and training.

260. Many GDC staff expressed the desire to work more collaboratively with their peers.

261. Although there was discussion of national and regional networks, these were not yet sufficiently established to maximise the opportunities for learning and sharing best practice. Efforts were being made to establish and maintain local networks, for example, with primary care teams. However, while this benefitted patients local to the GDC, it was understandably challenging for the clinics to create and develop networks beyond their region, despite GDCs offering training via Teams events.

262. Many of the GDCs had invested in education and training surrounding the wider healthcare needs of the transgender population.

263. A number of clinics also had strong links with local educational facilities, such as universities, to help educate future healthcare professionals in the potential needs of transgender patients.

Training the wider NHS

264. The NHS must ensure all patients, including transgender patients, are treated within a compassionate, fair and positive culture.

265. Some non-GDC clinicians are hesitant to engage as they lack confidence in their knowledge and skills when working with transgender patients, feeling uncertain about the appropriate language to use.

266. NHS staff across all services need to be aware that transgender patients may need to be cared for and treated for other conditions, in any part of the NHS.

267. The patient survey reported a need for more training and awareness raising among the wider healthcare services of the needs of the transgender population to ensure more inclusive practices are considered and used.

268. It is impossible for the GDCs alone to inform and train the NHS. Consideration should be given to the inclusion of transgender awareness and care into training syllabuses for all NHS staff.

269. Professional bodies, regulators and healthcare training providers should consider the development of undergraduate, postgraduate and profession-specific training in healthcare for the transgender population that aligns with their expectations of best practice.

270. The review has proposed the potential development of enhanced services to support the prescribing of hormones in primary care, which could also act as an educational resource for primary and secondary care.

Appointments and staff time 

271. Clinical productivity is mainly measured by the number of patient appointments for assessments and follow-up.

272. There is significant variation in the number of appointments undertaken by each whole-time equivalent (WTE) clinician between the GDCs, with a fourfold difference in activity between the GDCs.

273. Some GDCs had fairly low levels of clinical activity compared to others, and these clinics usually had the longest waiting times.

274. Appointment times for assessment and follow-up also varied, with some GDCs booking appointments for 2.5 hours, including clinical administration time. There is an opportunity to standardise these appointments and processes across the GDCs.

275. There was evidence that most GDCs were introducing newer models of care, with the use of skill-mix, such as nurse-led clinic appointments and non-medical prescribing.

276. The use of job planning at an individual and team level could improve GDC productivity and reduce patient waiting times for first assessment.

277. A few clinics had undertaken a review of clinical and non-clinical job plans to try to optimise GDC resources. One clinic had a very proactive approach to the use of clinical time and, in doing so, had significantly increased clinical capacity and reduced patient waiting times. In doing so, that clinic had received more referrals. Other GDCs need to learn from this improvement work.

278. The administrative burden posed a challenge for clinicians and administrative staff at all GDCs. This was partly due to insufficient administrative staff who had to manage the GDC’s long waiting list while also handling enquiries and calls from distressed patients.

279. Clinicians shared that they could spend 1 hour after an assessment writing up the patient’s record. This is not a good use of clinical time.

280. GDCs should look at how NHS-approved artificial intelligence (AI) might be used to support efficiencies, including transcription of clinical notes and letters to reduce the amount of clinical time spent on administration.

281. The new National Quality Improvement Programme for Adult Gender Services provides an opportunity to bring all commissioned GDCs together to share best practice and to standardise care processes for less complex cases, ensuring the best care and outcomes for patients.

Did not attends (DNAs) and clinic appointment cancellations

282. The GDCs report DNAs as appointments that have been cancelled by the patient or the clinic, or where the patient failed to attend. Table 8 indicates around 81.5% of first assessment appointments are attended.

Table 8: Average monthly first assessment appointment activity across all adult GDCs based on a 6-month average

Source: Arden and GEM Commissioning Support Unit GDC monthly activity return, October 2024

Table 9: Average monthly follow-up appointment activity across all adult GDCs based on a 6-month average

Source: Arden and GEM Commissioning Support Unit GDC monthly activity return, October 2024

283. The clinics are, on average, currently scheduling 10 times as many follow-up appointments than first assessment appointments. For some GDCs, the number of follow-up appointments is 20 times the number of first assessments. Some clinics have been unable to discharge patients back to their GP, and the long surgical waits have also prevented patients being discharged.

284. Just under a quarter (24%) of all follow-up appointments are missed due to cancellations or non-attendance.

285. The review heard from many GDC staff that some patients’ non-attendance was due to additional conditions, such as neurodevelopmental conditions, which could impact how they plan and schedule their lives.

286. Valuable administrative resource is used reaching out to patients who DNA to discover they have already been seen by other clinics or services.

287. However, 1 GDC had responded to this change in the referred patient group by adapting its communication to patients’ preferences. In making this proactive change, they had reduced the number of clinic and patient cancellations to almost zero for both first assessments and follow-up appointments. This example of patient-focused care should be part of the future National Quality Improvement Programme for Adult Gender Services.

Culture, leadership and governance

Leadership and culture

288. As outlined in the NHS leadership competency framework for board members, strong and active leadership helps shape and deliver a compassionate and just culture and enable positive experiences for patients and staff, as well as good outcomes. It is important that everyone feels safe and supported when accessing or working within adult gender dysphoria services. The service specification sets out that a nominated senior clinical lead should have the key leadership role for the overall service.

289. The review found variation in clinical leadership across the GDCs, ranging from psychiatry-led and psychology-led services to newer models with a GP with additional specialist skills.

290. The review witnessed a range of leadership styles during its GDC visits. As with any service, good leaders should be able to adapt and respond effectively to the needs of their teams, and as such, there is not one right way to lead. Despite this, GDCs and their host organisations, supported by regional teams, must ensure their leaders adhere to the basic principles defined within the NHS People Promise.

291. The review heard from a few GDC staff members that they did not feel psychologically safe working in their service. They did not feel empowered or encouraged to raise concerns or issues within shared forums, such as multidisciplinary team meetings. They felt clinical curiosity or constructive challenge was discouraged, issues raised were dismissed as transphobia or prejudice, or their voice was not valued due to their role or perceived lack of seniority within the GDC.

292. By contrast, other GDCs demonstrated collegiality and collaboration. Staff from all professional backgrounds and experience levels were welcomed to forums such as multidisciplinary team meetings. Staff felt their contributions were encouraged, valued and appreciated. The review heard directly from staff at these GDCs about how much they enjoyed and were supported in their roles and felt this reflected in the care they were able to provide to patients.

293. It is important to reiterate the significance of the multidisciplinary team meeting, the performance of which is optimised when undertaken by a high-performing, cohesive clinical team, supported by others, including senior managers and administrative staff.

294. The review also saw examples of where new operational service managers (many of whom brought in skills, learning and experience from other service areas) had begun to implement new or innovative practice or strategies to support service improvement, including the development of dashboards that tracked each patient’s journey through the care pathway. There were also some good examples of changes to clinical processes, which have improved patient flow, reducing patient waiting times for patients.

Governance and oversight

295. The service specification states that there should be a robust system of corporate governance, including a nominated senior manager, which demonstrates effective management, guidance, oversight and accountability by the host organisation (board level or equivalent).

296. NHS England regional specialised commissioners also have a role in providing oversight of the GDCs and their host organisations to ensure high-quality services. This includes monitoring adherence to the service specification and oversight of waiting times. This is managed through regular meetings between NHS England regional specialised commissioning teams and the GDC host organisation.

297. The review found there were inconsistent levels of governance and oversight across host organisations. Some GDCs had clearly articulated, approved processes and reporting routes in place for any risks, incidents or issues relating to the services, with options for escalation where appropriate or required. There was ownership across both the GDCs and host organisations regarding the implementation and management of actions that would mitigate or address any risks raised.

298. Other GDCs and host organisations lacked this robust approach, with clear service risks, such as the waiting list backlog not captured within some board-level risk registers. Where waiting times were captured – such as within board performance reports – little or no discussion around addressing this was evidenced at some trust board meetings. At times, it appeared the extended waits were considered a “normal” part of this service, with no solutions being offered.

299. The review also saw examples of clinics or host organisations being unable to identify or locate any documentation detailing service incidents and a lack of ownership regarding safeguarding referrals.

300. As with any service that carries clinical risks, it is vital that trust boards have clear oversight of these services and can respond promptly when their GDC requires additional support and oversight.

301. This will be particularly important as the GDCs participate in the proposed National Quality Improvement Programme for Adult Gender Services. Unsurprisingly, clinics with close relationships and stronger oversight from the trust’s senior leadership had clearer lines of accountability and more robust processes, including risk management.

302. This closer alignment between the host organisations and GDCs provides an opportunity for the GDCs to tap into and benefit from organisation-wide resources. For example, trust improvement teams can support improved team job planning to sustainably reduce waiting times.

303. The review did see positive examples of where GDCs had used available resources from the host organisation to improve team job planning, leading to a standardisation of appointment times and resulting in a significant increase in first assessment appointments for patients, as well as a reduction in the time to be seen from referral.

304. The review observed a mixed picture regarding the scrutiny and engagement provided by NHS England regional specialised commissioning teams.

305. A lack of access to national data has resulted in limited opportunities for regional collaboration, sharing of best practice and identifying variations between GDCs.

306. The monitoring and management of risk within the GDCs from a regional commissioner perspective was, at times, limited. Regional specialised commissioning risk registers only occasionally highlighted areas such as the long GDC waits and did not outline mitigations or solutions with specific dates for improvement.

307. Although the NHS England regional specialised commissioning teams and Arden and GEM Commissioning Support Unit have been working to understand the challenges and opportunities for improvement within the GDCs, there has been no significant impact on waiting times.

308. There is an opportunity to improve governance and oversight arrangements for these services. Closer working between GDCs, host organisations and regional and national commissioning teams – with support from the National Quality Improvement Programme for Adult Gender Services – can help drive and deliver those improvements.

309. This review calls for a whole healthcare system response. This is not just a specialised commissioning issue. Primary care and ICBs also need to respond. To do that and ensure delivery of the review’s recommendations, NHS England should set up a national adult GDC oversight board, which will include representatives from NHS England, appropriate royal colleges, VCSE organisations, ICBs and primary care leaders.

310. That oversight board will receive a national implementation plan, with clear milestones regarding the delivery of this review’s recommendations. That plan should be developed collaboratively with local commissioners, primary care and others, including the VCSE sector.

311. Each GDC, in collaboration with its host organisation, needs to respond to the National Quality Improvement Programme for Adult Gender Services to develop an action plan. This will need to be signed off by their host board, who will need to appoint an executive lead for this work, and NHS England. Both the board and NHS England must then monitor it to ensure progress.

312. To enable all the GDCs to benefit from the National Quality Improvement Programme for Adult Gender services a formal national clinical Provider network should be established with an independent chair. This network could also work in partnership with the existing CYP Gender National Provider Network.

Role of integrated care boards

313. Integrated care boards (ICBs) are responsible for the local strategic commissioning of health services for their population, including primary care, secondary care, mental health services, as well as services from the VCSE sector. ICBs are not responsible for the retained specialised commissioning services, such as the commissioning of the GDCs. It is important to note that while patients are on the waiting list to be assessed by the GDC, their care remains the responsibility of primary care, which is commissioned by ICBs.

314. ICBs are also responsible for improving population health. Transgender patients have described feeling marginalised by health services.

315. Although the service specification was written before ICBs were formally established, ICBs are responsible for commissioning certain non-specialised elements of the NHS pathway of care for individuals with gender dysphoria, including gamete storage and stand-alone surgery that sits outside of the GDC patient pathway. It may also be appropriate for non-gender-related voice and communication interventions to be provided by non-specialised services commissioned by ICBs.

316. While some GDCs do offer some support to patients on the waiting list, ICBs are responsible for commissioning the non-specialised healthcare needs of this population and need to ensure they have appropriate access to care in advance of and alongside the GDC assessment process. This includes healthy weight management and access to appropriate local mental health services if necessary.

317. ICBs also have a role in supporting primary care with long-term hormone prescribing to these patients and will be involved in the delivery of the proposed pilots.

What good looks like

318. Commissioners, boards and GDC clinicians will want to use the review findings and recommendations to build a configuration of providers that are capable of meeting the requirements of the NHS service specification, and to embed quality improvement initiatives within the existing services. 

319. Compassionate, safe and high-quality service depends on critical components that all organisations hosting a GDC must be able to demonstrate.

Effective leadership 

320. Strong and active leadership will help facilitate a team approach to care, promote innovation and enable wider collaboration across GDCs and local healthcare partners.

321. Each GDC should act as a resource for their region – offering training or support to ensure new staff and wider services understand the needs of the transgender population. This will include engaging primary, secondary, community and VCSE sector to ensure patients get appropriate care along the pathway.

Positive culture 

322. A compassionate, safe and positive culture will support GDCs to be open and inclusive environments, where the best possible care can be delivered by staff for patients.

323. Opportunities to learn and improve will be key, ensuring GDCs are able to continually develop and can create a workforce that feels empowered to share and grow their skills and knowledge. Staff surveys offer an opportunity to assess and strengthen positive organisational culture.

Robust governance 

324. Robust systems of governance should be in place to oversee these services and help drive continuous improvement, with strong and effective oversight, guidance and accountability provided by the host organisation.  This should include: 

• board oversight, with an annual visit and any risks recorded as outlined in the trust policy 
• board support for the delivery of the GDC improvement plan, ensuring there is a clear 3 to 5-year strategy for the service 
• the trust or organisation having an accurate and up-to-date understanding of the financial costs of the service  

Quality  

325. With the adoption of standardised assessment processes, consistent reporting of data, collection of patient experience feedback and encouragement of clinical curiosity to undertake and share research and audits, GDCs will deliver high-quality care that is effective, safe and provides a positive patient experience. 

Improvement programme 

326. A National Quality Improvement Programme for Adult Gender Services will support individual and system-wide initiatives to drive and deliver progress and improvements across the GDCs. This will include:

• working within a collaborative national GDC network 
• supporting GDC to develop and deliver an improvement plan
• supporting local improvement initiatives, such as individual and team job planning 
• supporting with the digitisation of clinical processes where possible
• reviewing the use of multidisciplinary team meetings every 6 months

Appendix 1: Review methodology

Principles

The review process was undertaken with a focus on improvement and guided by the following principles:

• the welfare of the service user was paramount, and concerns were escalated to appropriate bodies in real time
• we worked with the GDCs and NHS trusts to identify areas of good practice and improvement
• we built patient public voice (PPV) participation into the review methodology; the panel sought the views of service users (past and present) at each GDC
• staff (past and present) were given the opportunity to have open conversations about the quality of care and provide suggestions on how services could be improved
• we were open and transparent – we committed to making information about the review available on the NHS England website

Process

The GDCs submitted documented evidence against the key lines of enquiry (KLOEs) in advance. This was shared with panel members before each GDC review visit. The review panel used the KLOEs, and evidence provided to inform and identify areas for further exploration at each visit.

The review comprised a series of 1-day visits by a review panel to each of the 9 commissioned adult GDCs.

During the site visit, the panel members first of all heard comments and opinions from patients who had been assessed and treated at that GDC as well as feedback from that GDCs patient workshop. Panel members then conducted a walkaround of the clinic site, meeting with available staff members. Panel members split into groups to meet with GDC staff, further exploring the delivery of the KLOEs and providing staff with the opportunity to discuss areas for improvement and examples of good practice. Panel members who are members of a relevant professional body had the opportunity to review redacted and anonymised case notes.

A meeting was held with trust or organisation senior clinical leadership, medical and nursing directors, or equivalent members of the executive team.

The review visit concluded with a high-level feedback session, outlining areas for improvement, best practices and any identified risks or concerns that required immediate action.

Following the visit, each GDC received written feedback that identified good practice and areas for improvement. NHS England’s National Quality Improvement Programme for Adult Gender Services and regional teams will work with the GDC and host organisations to take forward the areas identified by the review.

Review panel

Dr Levy was supported by an expert panel from members of:

• the Association of Clinical Psychologists UK (ACP-UK)
• the Care Quality Commission (CQC)
• the Royal College of General Practitioners (RCGP)
• regional medical and nursing directors for specialised commissioning
• clinical leads of integrated care boards
• gender experts from other GDCs

The Royal College of Psychiatrists supported Dr Levy in examining evidence submitted to the review and in listening sessions with GDC clinicians.

Review governance

The review was supported by a steering group comprising NHS England commissioners of adult gender services, members of the review team and representatives from the Department for Health and Social Care. Representatives from NHS Wales also attended in an observational capacity.

Outputs

The review committed to producing the following key outputs:

• a national report bringing together the key findings from the visits to the GDCs, evidence submitted, including the patient, family and staff survey and workshops, and by stakeholders and professional bodies
• clinics to receive individual letters outlining key areas for improvement, along with any good practice identified
• future work with the National Quality Improvement Programme for Adult Gender Services, including reviewing the non-surgical and future surgical service specification