NHS England has walked back its plans to limit who can refer patients to its service for transgender children, after proposing to shift all responsibility for referring onto just GPs and healthcare professionals.
Previous guidelines allowed teachers, staff in voluntary organisations and people working in social services to refer children for NHS support, but draft proposals published last year suggested removing that referral capability.
NHS England had said that 65% of referrals were already made by GPs.
But a consultation has now revealed that 57% of the 5,183 respondents – including clinicians, patients and parents – disagreed with the change, with a number suggesting it was unclear how the new referral procedure would work.
NHS England will instead form a separate second service specification that ‘will describe in greater detail the process for making referrals onto the national waiting list’ held by NHS Arden and GEM commissioning support unit (CSU), due by the end of the summer.
The confirmation comes as part of NHS England’s finalised interim service specification for caring for children with gender dysphoria, published this weekend (9 June).
This first specification sets out that the service itself will offer patients an individual care plan, delivered by an integrated multidisciplinary team (MDT) but stops short of detailing who can refer into the service.
It comes after the BMA warned last year that GPs are having to conduct ‘extensive reviews’ for patients referred to the adult services to assist with extraordinary waiting lists.
GPs have now warned that the added workload would be unmanageable and may lead to referrals being dropped or left unfinished.
Dr Sam Hall, GP partner at Brighton Health and Wellbeing Centre, said: ‘NHS England will be setting up another aspect to the service to manage referrals, so that means referrals will be going into a central holding bay. It looks to me like they’re going to create another, secondary layer of obstruction [to care] effectively.’
Dr Hall said that the additional workload associated with the referral would risk limiting the number of successful referrals.
He said: ‘The barriers that make it hard for a GP to refer are as simple as one referral form taking half an hour to fill out. We don’t have half an hour – I don’t have time to see all the patients who need to be seen in a day.
‘Many GPs either will not get round to it or may take their time with it. None of this is deliberate. The risk is that GPs will be obstructed by how difficult they have made the referral.’
A second analysis of the consultation – commissioned by NHS England and led by social research specialist TONIC – suggested that patients and parents of transgender children saw GPs as ‘unknowledgeable about trans healthcare issues’.
This was identified as a further barrier to treatment, with queries raised as to how one might obtain a second opinion if GPs stand as one of only two referral sources, alongside other healthcare professionals.
Respondents to the consultation also questioned whether it was ‘realistic’ to expect the provision of the resources and funding needed to better educate practitioners.
TONIC’s report also revealed that a number of respondents questioned whether the referral responsibility would be better placed with and adult who knows the child well, which they saw as ‘unlikely’ to be a GP.
NHS England also confirmed it would stop prescribing puberty blockers to under-18s, unless they consent to partake in a research study looking into their effects or in exceptional circumstances.
Puberty blockers are sometimes prescribed to transgender under-18s as a means of pausing puberty development to treat gender dysphoria.
LGBTQ+ charity Stonewall said the restriction ‘cannot be right’, stating that treatment ‘should be based on clinical need, and coerced participation in research is unethical’.
The new interim service comes in the wake of the Cass Review, an ongoing assessment of the current Gender Identity Development Service (GIDS) pathway, run by the Tavistock and Portman NHS Foundation Trust, North London.
Published last summer, the interim report recommended the Tavistock service – the only one of its kind in England – be discontinued and replaced by several regional hubs, suggesting the former single specialist provider model was neither not a safe nor viable.
This new regional approach will be launched on the basis of this specification in two ‘early adopter’ sites, with a view of opening more services in 2024.
The CQC’s inspection of the previous GIDS service in October 2020 found that there were 4,600 children and young people on the waiting list, with wait time of over two years to their first appointment.
And the BMA warned last year that GPs are having to conduct ‘extensive reviews’ for patients referred to the adult services to assist with extraordinary waiting lists.
For more information on providing care for trans patients, visit the Pulse CPD module.
Be careful. When the Tavistock became overwhelmed by a massive increase in referrals (and simultaneously increasingly staffed by gender idealogues), there was a rush to merely “affirm and treat” children with gender dysphoria . With lawsuits from (now adult) detransitioners piling up, whilst at the same time we are threatened with medicolegal oblivion if we even question the child’s gender identity (“conversion therapy “, apparently, despite the obvious effect of Social Contagion we have seen before, especially in teenage girls (anorexia in the 90s, self harming in the noughties)), it puts clinicians in an unenviable and uncomfortable position.
If the new service promises counselling, respect and compassion, but withholds drugs and surgery until aged 18, then fair enough, but the prospect of numerous mini Tavistocks nationwide fast tracking children into potentially irreversible treatments is terrifying. A lot more reassurance and guidance for children, parents and GPs is essential.