Landmark trans care review recommends GP referral as sole pathway to gender services
A landmark review into adult gender dysphoria clinics in England has recommended that a GP referral should be the only pathway to adult trans services.
The newly published review, led by medical director and cancer specialist Dr David Levy, investigated the safety and effectiveness of nine gender dysphoria clinic (GDC) services in England.
Commissioned by NHS England in June 2024, the review has now identified ‘exceptionally long waiting times’ for gender services reported, a lack of knowledge-sharing between GDCs, and absence of patients waiting lists or outcomes data.
It said NHS England should ‘standardise and streamline’ referrals by working with GDCs to ‘establish GP referral as the only pathway to adult gender services, with an end to self-referrals’, as well as ‘support more informed GP referrals and GDC triage processes by developing a standardised patient form for GDC referrals’.
Review recommendation on GP referrals
To standardise and streamline the referral processes, NHS England should work with the adult GDCs through the National Quality Improvement Programme for Adult Gender Services to:
- support more informed GP referrals and GDC triage processes by developing a standardised patient form for GDC referrals, which is completed by the patient and captures relevant standardised clinical and social information
- establish GP referral as the only pathway to adult gender services, with an end to self-referrals
Source: Levy review
The review also found ‘many GPs’ felt they lacked ‘confidence’ and ‘the appropriate expertise’ around prescribing and monitoring hormone interventions, while some ‘feel they are being asked to prescribe off-label medications, which they perceive as creating risk’.
Dr Levy’s review said it ‘saw evidence of unhelpful and daunting correspondence’ from GDCs to GPs and called on NHS organisations to ‘establish how GDCs and GPs could work more effectively together, within the limits of GP competence’.
To address this, it suggested ‘using the GPs with Extended Roles (GPwER) model’ to support local hormone prescribing, following consultation with the RCGP, which also sat on the review’s expert panel.
The review said GP representative bodies including LMCs and the RCGP should play a key role in establishing ‘sustainable local arrangements’ for gender dysphoria care.
‘NHS England and ICBs should work with adult GDCs and GP representative bodies – such as Local Medical Committees and the Royal College of General Practitioners (RCGP) – to establish sustainable local arrangements for hormone prescribing and access to longer-term health monitoring’, it said.
In a position statement on transgender care published earlier this year, the college said it was ‘open to exploring the creation of a framework for a GPwER for care of adults in this area’ where it was ‘suitable for the local population’.
The Levy recommendation said GDCs should manage hormone prescribing for patients for at least a year before discharging patients to primary care, and that ‘non-medical prescribers’ could form part of the primary care team managing the life-long prescribing process ‘where clinically appropriate’.
ICBs and NHS England should also explore supporting GPs and primary care through new local enhanced services or a national network of endocrinologists ‘when concerns arise’, the report said.
Recommendations for hormone prescribing
NHS England and ICBs should work with adult GDCs and GP representative bodies – such as Local Medical Committees and the Royal College of General Practitioners (RCGP) – to establish sustainable local arrangements for hormone prescribing and access to longer-term health monitoring. This should include:
- developing local hormone prescribing pilots, potentially using the GPs with Extended Roles model or other local models of care
- every ICB ensuring there is local primary care support for the prescription and monitoring of hormones for their transgender population
- GDCs managing hormone prescribing for patients for a minimum of 1 year until levels are stable, before discharging patients to primary care. Where clinically appropriate, non-medical prescribers could form part of the primary care team managing the life-long prescribing process
- local transgender hormone prescribing services offering patients an annual review, including checks for cardiovascular disease or risk and screening advice
Alongside this work, NHS England should consider establishing a national endocrine network to support primary care with prescribing during key life stages and health challenges to ensure patient safety.
Source: Levy review
The review further recommended creating a National Quality Improvement Programme for Adult Gender Services, which should ensure ‘patients and their GPs receive clear communication about available local support options’ during referral to NHS adult gender services.
Professor Azeem Majeed, a GP and head of the department of Primary Care and Public Health at Imperial College London, told Pulse: ‘The proposal to move toward a single GP-led referral pathway by ending self-referrals could improve clinical coordination, ensuring that a patient’s full medical history is considered from the outset.
‘However, this shift places GPs in a sensitive gatekeeping role for a highly specialised service. Without protected time, accessible guidance, and clear lines of clinical responsibility, there is a real risk of adding pressure to already stretched primary care teams and inadvertently creating new barriers for patients seeking timely care.
‘The introduction of a standardised national referral form could help bring greater consistency to the information GDCs receive. For this to work well, though, the form must be practical and proportionate—grounded in what a GP can realistically assess within a routine 10–15 minute consultation, rather than requiring a specialist-level assessment at the point of referral.’
Dr Majeed welcomed the proposals to support GPs if self-referrals ended saying it ‘would provide both the medicolegal assurance and the clinical expertise needed to make this model sustainable’.
‘Ultimately, any shift toward a more GP-focused pathway must be underpinned by the principle that capacity should precede responsibility. These recommendations offer a clearer roadmap, but they will only be effective if accompanied by immediate investment in training and specialist support.
‘Without those safeguards, there is a risk of simply shifting workload to primary care rather than meaningfully improving patient experience or clinical outcomes’, he said.
Responding to the review’s publication, NHS England said it would ‘bringing an end to self-referrals into the service’ and would establish ‘a new professional role of GP with an Extended Role in Gender Medicine’.
Nottingham GP Dr Irfan Malik said the proposed recommendations around GPwER ‘sounds like a better plan’ than the current situation.
Dr Malik said: ‘GPs are used to referring to lots of different services, but if there’s a specialised GP, a specialised service that can deal with the next steps, then that would be more appropriate.’
He said that, currently, ‘a lot of the prescribing and monitoring is over to the GP’ despite it being ‘an area we’re not skilled in monitoring or initiating prescribing’.
‘If there is a more appropriate, specialised service that we can refer to, that would be much better for us’, he said.
In September, a survey of GPs found insufficient medical training was a frequent barrier to supporting transgender patients. The report also argued an inability to access shared care agreements with private clinics or NHS-funded gender identity clinics (GICs) prevented GPs being able to prescribe gender-affirming hormone therapy.
Pulse has reached out to RCGP for comment.
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READERS' COMMENTS [5]
Please note, only GPs are permitted to add comments to articles
This is a super specialised area that needs super specialist who are trained to do this safely. 99% of GPs have no training in this area and are not in a position to help in this area safely. Either a commisioned service in hospital to monitor and prescribe on an ongonig basis, or a GYPSI team (again for long term ongoing prescribing and monitoring ) should be the norm. GPs can carry on doing routine general practice rather than risking harm due to knowledge and training. Quite simple.
GPs should be able to decline prescribing based on lack of confidence in the rigour of science and medicine in this domain. Let those who are confident this is the correct thing take on the long term prescribing.
I agree that it seems essential for Clinics to have access to a proper GP referral along with current and past medico-social history, and including contraindications or pre-priority items, like ensuring general capacity to consent and lack of interfering mental health conditions – ability to prepare the patient for referral perhaps.
But we now have Electronic Prescribing Systems.
So why is ANYONE mentioning ‘shared care prescribing processes’? It is as easy, if not easier, for the Consultant to enter the drugs they wish to prescribe into the repeat prescribing system, and periodically request screening measures and review the medication and effects; rather than to write to GP instructing that GP take on prescribing responsibility for something OUTSIDE their area of expertise (and therefore contrary to GMC guidance).
This is just two things 1) Trusts dumping prescribing costs on Primary Care;
2) Consultants trying to offload inappropriately their responsibility for providing ongoing care and review of thier own prescribing, and any associated medicolegal issues.
Letter to GP is essential for safe shared care, but the Clinic Doctor can now take responsibility for issuing prescriptions themselves, if they are willing to take the salary that comes with their jobs.
I have seen documentation from a GDC directing the GP to initiate treatment. When the GP responds with questions, a very threatening-sounding response is sent, basically telling the GP to prescribe or else. It is a non-veiled threat to the GP, looks like a form response, also so I doubt it was a one-off. All other specialist services that I am aware of initiate medication themselves and do the initial monitoring until stabilised
No.
Not an illness. Not my job.
The ‘treatment’ of this not illness is specialist. Not my job.
I keep my medical nose out of how my patients wish to present to and engage with the world. The hobbies, interests, relationships. chosen aesthetics and bodily modifications of compos mentis adults are their business not mine.
I would no more refer to a gender identity clinic than a religious gathering or tattoo parlour. They are all ideological choices , not illnesses and the views of a GP as to their suitability to be pursued by any autonomous citizen are irrelevant.
Patients have access to their own records now, and if such records are so important to the processes of a gender clinic, they are free to peruse as they see fit , with patient consent.