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GPs go forth

GPs should initiate gender dysphoria hormones in 'exceptional circumstances'

The GMC has said that GPs should initialise hormones to patients with gender dysphoria only in 'exceptional circumstances', after its original guidance was questioned by the GPC.

A letter from GMC chief executive Niall Dickson to GPC chair Dr Chaand Nagpaul said these 'bridging' prescriptions, while a patient was awaiting a specialist appointment, should only be considered when three criteria were met. 

He defined these as:

  • The patient is already self-prescribing with hormones obtained from an unregulated source (over the internet or otherwise on black market);
  • The bridging prescription is intended to mitigate a risk of self-harm or suicide;
  • The doctor has sought the advice of a gender specialist, and prescribes the lowest acceptable dose in the circumstances.

Mr Dickson said the GMC will now 'review the wording' of its new guidance 'to make sure it's clear to doctors that it's only in these exceptional circumstances that bridging prescriptions should be considered'.

The GPC had also raised concern regarding continued prescriptions under shared care arrangements, which it said went against GMC Good Medical Practice by 'forcing' GPs to prescribe 'outwith the limit of their competence'.

But Dr Dickson said that 'this principle' cannot 'be a bar to doctors taking on new responsibilities or treating unfamiliar conditions'.

He said: 'We would expect GPs to acquire the knowledge and skills to be able to deliver a good service to their patient population... Having said that, we don't believe that providing care for patients with gender dysphoria is a highly specialist treatment area requiring specific expertise.'

He added that he 'sympathetic' with the 'difficult position' GPs were placed in with regards to long referral waits, offering to be 'part of conversations' with NHS England on how to 'help make sure that trans patients are able to access the specialist services they need'.

Readers' comments (25)

  • "we don't believe that providing care for patients with gender dysphoria is a highly specialist treatment area requiring specific expertise."

    In that case, why do gender clinics insist on months of psychological assessment before they will consider issuing hormone prescriptions?

    Whereas you seem to be advising that a GP should just print out a prescription in a 10 minute consultation.

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  • Vinci Ho

    More interested to know the 'story' behind , driving this so high profile announcement by GMC?

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  • Vinci Ho

    He said: 'We would expect GPs to acquire the knowledge and skills to be able to deliver a good service to their patient population... Having said that, we don't believe that providing care for patients with gender dysphoria is a highly specialist treatment area requiring specific expertise.'

    Mmmm , logically and potentially this can apply to virtually all other 'specialist' therapy . The happiest organisation is our medical indemnity agencies with all reasons to ramp up the fees higher and higher. And to the patients , really safe enough , seriously ?

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  • I read this as a pretty straightforward plan to dump a really very tricky area of practice on to GPs. It is only a matter of time before someone commits suicide while waiting for a clinic appointment - "If only the idle GP has just done what the GMC said and prescribed the hormones."

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  • "'We would expect GPs to acquire the knowledge and skills to be able to deliver a good service to their patient population... "
    Correct- in the 50 hours of postgraduate learning per annum specified by the GMC;
    based on an assessment of the practices populations needs and most benefit from time spent as per appraisal and revalidation.
    The thorny issue is the circumstance arises so infrequently that spending the time for one or two individuals looses out to the hours of " mandatory" child protection; Information governance etc.
    and keeping abreast of the changes in therapy that benefit hundreds of patients in a what little time remains after an increasingly complex and expanding service delivery of care.

    Definition of a specialist "someone who looks after a small section of health needs in a 30-60 minute outpatient appointment because the condition is "beyond GP capability" - until the condition rises in prevalence at which point it becomes a "GP problem" but unfortunately still in a 10 minute slot and not a sixty minute one........

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  • Dear All,
    Err but "The patient is already self-prescribing with hormones obtained from an unregulated source (over the internet or otherwise on black market);"

    If the source is unregulated and its self prescribing how can anyone be certain they are actually receiving bio active compounds? More likely the 90% talc Viagra discovered above a north london shop years back.

    if there is no certainty that the patient is actually on a hormone treatment then the GP would in effect be initiating treatment.......

    I think Mr Dickson should re-consult his advisers on this aspect.

    Regards
    Paul C

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  • Vinci Ho

    The falsification in philosophy is worrying . Specialist defines oneself by seeing multiple cases sharing similar pattern in a specialised field and it is exactly the number of cases one seeing daily also defines the word 'experience'. That is why cardiologist cannot see a patient with rheumatoid arthritis and one can argue GP is a specialist of upper respiratory tract infection because of the number of cases we are seeing every day. Training and experience are clearly completely separate concepts.
    If the clause 'exceptional circumstances ' is adopted by GMC , it means logically 'minority' cases . Why is it not even more essential that they should be treated by those with more experienced in the therapy in question ?

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  • err....shouldn't this be initiate?

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  • Peter Swinyard

    Good luck with the MDO's when you are sued. Working within your scope of expertise is a fundamental of good medical practice, if not Dickson's idea of Good Medical Practice with the capitals.

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  • No. This is not general practice.

    I find it quite astonishing that efforts are being made to force GPs to take prescribing responsibility outside their competence and against their better judgement in this one very specialised area and wonder if it's a lack of specialists willing to see and medicate that is the issue. We retain prescribing responsibility so have to retain prescribing independence; that is the principle (rather than Mr Dickson's "principal") at stake here.

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  • But Dr Dickson said that 'this principal' cannot 'be a bar to doctors taking on new responsibilities or treating unfamiliar conditions'.
    Shouldn't that be "principle"?

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  • these pt's needs a psychiatry referral not a prescription

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  • If the patient develop PMT type symptoms and kill themselves due to you prescribing outside your competence an UNLICENSED medication you will be charged with manslaughter.

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  • Remember Nigel Dicksons background is journalism. . What does he know?

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  • “The bridging prescription is intended to mitigate a risk of self-harm or suicide;”

    “I’m going to top myself if you don’t prescribe” is not an uncommon coercion used by manipulative individuals who want to get their way. I am unhappy that this is being cited by an organisation that, itself, is implicated in some 28 doctor suicides as they take their languid time investigating.

    And what protection is the pressured prescriber to have if the patient suffers or dies from the drugs that are clearly outside the remit of GP?

    Devil and the Deep Blue Sea. That’ll be a NO then.

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  • 1. Why are the GMC getting involved in clinical issues I thought they were a regulator. NICE might stick thri nose in sure but GMC??
    2. Why are the GMC telling us to break their own guidance of good medical practice and start treating conditions were not trained to treat and have no experience of.
    3. They are suggesting we give patietns hormones appropriate for the opposite sex without the proper psychiatric assessment and other ( I have no idea) work up which is required before embarking on suck life changing treatment.

    How about accepting there is a wait time and in the interim attempting to increase the number of doctors working in the area of gender reassignment.

    This is just more dumping because we are free. This eat all you like contract is not only bad for GPs who foolishly agreed to unlimited workload for a fixed fee but also bad for patients as it encourages even those bodies set up to protect doctors and patients to push work on un were not qualified to do purely becase its the cheapest way of getting it done.

    Terrible really. The NHS is truly becoming 3rd class. The DM readers wouldn't want their tax money going on sex changes. I can imagine the headlines.

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  • a pt of mine has no difficulty obtaining branded oral contraceptive pills which appear genuine via the internet and (s)he equally has no difficulty understanding that I wouldnt prescribe them outside of a specialist treatment plan.I can't think of any other conditions where a risk (or threat) of suicide would be best treated by an otherwise unlicensed prescription. (nb please don't anyone start a debate over the gender pronouns)

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  • These patients are suffering from severe mental and emotional issues that are beyond the scope of practice of the GP. They require specialized treatment by properly trained psychiatric personnel. IMHO dumping this mess on the GP to score a few points with the constituents is a huge mistake.

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  • Cynical outrageous dumping
    Dangerous nonsense from GMC ., and what on earth has this clinical issue to do with them?
    Beyond ludicrous
    Exceptional circumstances is NEVER
    No GP should ever manage anything outside their competence .. Would you not agree GMC?
    I say again
    What an utterly pathetic piece of grossly dangerous nonsense
    Whoever came up with this feeble drivel should be reported to the GMC!

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  • Every time I read pulse there is yet another example of the surreal incompetence of our out of touch delusional London bureaucracy
    Incredible

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  • This guidance is very worrying and contradictory as the GMC states not to manage conditions out of your area of expertese. We cannot be an expert in everything. What's the college doing to address this?

    Where will this end? Will we have to do our own tummy-tucks if our patients feel their stomach is giving the
    significant anxiety and the CCG won't fund it?

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  • Maybe the GMC should pay for our indemnity then,and I still wouldn't do as we have absolutely no experience in this area.The lunatics have well and truly taken over the asylum.

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  • This is clearly bonkers - but there's an interesting point when they say that they require that "the doctor [GP] has sought the advice of a gender specialist, and prescribes the lowest acceptable dose in the circumstances."

    Our local gender service refuses to advise for patients who have not completed their lengthy assessment pathway (a pathway that typically only starts after a 3-year-plus wait).

    So in my region there would automatically be no patients for whom the GMC "exceptional circumstances" apply.

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  • The only reason this is happening is so that the GP can be sued when the patient on the waiting list for psychiatrist assessment commits suicide. Blame the useless GP!

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  • Someone please put us out of our misery. The joke is now over. GP is the most miserable farcical job in the UK. Go on Maureen et al hiding away - any chance of someone supporting your colleagues?, thought not. Just shoot us all, the thought of another 20 years of this brings me to tears.

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