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A recent post on Reddit highlighted some of the challenges being faced by trans people in the UK, when trying to access collaborative – or shared – care via their GP, this could include blood tests, prescriptions and injection administration. These are stories we are all too familiar with at GenderGP. Here we provide some guidance on what you can do if you are struggling to get help from your doctor.

The NHS Constitution states that patients in England have a right to start consultant-led treatment within a maximum of 18 weeks of being referred by their GP. Where patients have waited for more than 18 weeks, or are likely to have to wait for more than 18 weeks, the NHS has to arrange an alternative provision for treatment.

When it comes to supporting trans individuals of all ages, the NHS has been accused of failing in its duty of care. So much so that in October 2020, a transgender teenager started legal proceedings against the NHS for failing to provide the treatment that they needed within the legal timeframe.

With the current waiting times for both children and adult services measured in years, rather than weeks, this will be a landmark case for many patients in England.

Of course, you shouldn’t have to start legal proceedings to access the care you are entitled to. So let’s look at what you can do to encourage GP support without going down the legal route:

 

How does NHS funding work?

Clinical Commissioning Groups (CCGs) buy services for their local community from any service provider that meets NHS standards and budgets – these could be NHS hospitals, social enterprises, voluntary organisations or private sector providers. This means better care for patients, designed with knowledge of local services and commissioned in response to their needs.’

All NHS patients should have the option to supplement their NHS care with private care without the need for CCG approval.

 

So what’s the problem?

The key issue is that there is a lack of training and education for doctors working in this field of medicine. This is compounded by conflicting messages being fed through to doctors from their regulatory bodies.

The revised positioning statement issued by the CCG highlighted in the Reddit post is an excellent example. It states that, ‘GPs MUST only prescribe within their own level of competence.’ In this case, the patient’s GP interpreted the guidelines as an instruction to stop treatment, believing themselves to lack competence in the treatment of trans patients, and the individual was left without support.

In reality, hormone management is a core competency of any GP operating today, the interpretation, which influenced the GP’s decision, is that treating a trans patient requires additional expertise.

This is at odds with guidance issued by the NHS which states that: ‘Gender specialists may be from many different clinical backgrounds, some specialising in mental health: psychologists, psychiatrists, counselors or therapists, but they may also be GPs, endocrinologists, nurses etc.’

This is supported by the WPATH Standards of Care Version 7 which states that: ‘With appropriate training, feminizing/masculinizing hormone therapy can be managed by a variety of providers, including nurse practitioners, physician assistants, and primary care physicians (Dahl et al., 2006).’

Further, in a letter from Susan Goldsmith of the GMC written to the BMA in 2016, she wrote: ‘we do not believe that providing care for patients with gender dysphoria is a highly specialised treatment area requiring specific expertise.’

So how is it that some GPs feel that prescribing in this area of healthcare is outside their competence, when the medicines are often prescribed by the same GPs for other conditions?

 

Learn more about shared care with our Medical Hub

 

Specialist providers, such as GenderGP provide additional gender expertise where needed and, working with the GP, can deliver the best care to their mutual patient, within an acceptable 18 week time frame.

GPs should collaborate with private providers unless there is a very good reason not to.

According to the NHS Specialised Services Circular, SSC 1826 which provides guidance for GPs on working with private on-line gender specialists:

‘a GP may decline to accept responsibility for prescribing, monitoring and testing if the GP is not assured that the provider offers a safe service, or is not assured that the request has been made by an appropriate gender specialist as long as the GP is also satisfied that declining responsibility would not pose a significant clinical risk to the individual.

According to GMC guidance:

‘An experienced gender specialist will have evidence of relevant training and at least two years’ experience working in a specialised gender dysphoria practice such as an NHS GIC.’

Given that there are no UK NHS published guidelines for the care of transgender people, no NICE guidelines and no formal medical education, GenderGP specialists follow international guidelines and best practice.

GenderGP has been working with GPs providing collaborative care to trans patients since 2015.

It would not, however, be acceptable to simply refuse to treat the patient. GPs should discuss their concerns with their patient, carefully assess their needs, seek to understand their concerns and preferences; consult more experienced colleagues and provide care in line with the guidance in Good Medical Practice.

The position statement issued by the CCG highlighted in the Reddit post makes two further concerning points:

  1. Requests must be discussed with the local NHS GIC before commencing any intervention. This is required so that an appropriate management plan can be initiated incorporating suitable safeguards and monitoring.
  2. NHS England (NHSE) commission specialist gender identity centres. It is likely that GPs will be requested to prescribe hormones for patients that are under the care of a specialist NHS GIC. However, requests from a private GIC or provider must also be discussed with the local NHS GIC before commencing any intervention.

Private gender clinics play an important role in bridging the gap while patients wait to be seen on the NHS. Private gender clinics exist precisely because of the waiting times to appointments with the NHS Gender Identity Clinic, which stretch into years. As such, advising GPs that they must FIRST seek approval from the GIC on the treatment of an individual simply exacerbates the situation, adding to the already unconstitutional waiting times.

Having to take this step also contradicts the CCG assertion that it partners with private sector providers to provide ‘better care for patients, designed with knowledge of local services and commissioned in response to their needs.’

 

If you are struggling to get help from your GP, this template letter may help:

Dear Doctor,

I am a patient of yours, I am transgender which means that my gender identity is different to the sex I was assigned at birth and I am seeking gender-affirming care so that my hormone profile matches my gender. This treatment should be available to me on the NHS but due to very long waiting times and a lack of provision of local services, I am having to go privately, and I am asking that you help me with this.

The NHS Constitution states that patients in England have a right to start consultant-led treatment within a maximum of 18 weeks of being referred by their GP. Where patients have waited for more than 18 weeks, or are likely to have to wait for more than 18 weeks, the NHS has to arrange an alternative provision for treatment.

Waiting lists for Gender Identity Clinics stretch into years, and as such I have chosen to access care privately to prevent further unnecessary delay, which would be damaging to my mental health and general wellbeing. I would like you to work together with my private doctor to provide my prescriptions, blood testing and the administration of any injections I might need.

Doctors are advised to prescribe within their level of competence. Hormone management is a core competency for GPs and in a letter from Susan Goldsmith of the GMC written to the BMA in 2016, she wrote: ‘we do not believe that providing care for patients with gender dysphoria is a highly specialised treatment area requiring specific expertise.’

My gender specialists from GenderGP will provide all guidance in terms of the hormone levels I am looking to achieve and what blood tests and medication I will need to support this. They will fully advise you on the medication I need, the dose and strength, and any blood tests. They will also advise on the results of the tests and any changes that need to be made. I am asking that you carry out the tests and prescribe under their direct instructions and supervision. They are available to answer any queries you may have within 48 hours of receipt of an email.

Working in this way with GenderGP ensures I am able to access the care I need within the constitutional 18 week time frame.

Many GPs feel that gender healthcare falls outside their expertise, but according to the NHS Specialised Services Circular, SSC 1826 which provides guidance for GPs on working with private on-line gender specialists:

‘a GP may decline to accept responsibility for prescribing, monitoring and testing if the GP is not assured that the provider offers a safe service, or is not assured that the request has been made by an appropriate gender specialist as long as the GP is also satisfied that declining responsibility would not pose a significant clinical risk to the individual.

GMC guidance states, ‘It would not, however, be acceptable to simply refuse to treat the patient. Discuss your concerns with your patient, carefully assess their needs, seek to understand their concerns and preferences; consult more experienced colleagues and provide care in line with the guidance in Good medical practice.’

I am therefore formally writing to you to ask that you assist me with my gender-related healthcare. I do not feel that I should have to pay privately for something that should be available to me on the NHS. GenderGP will happily give you all the advice and support you need for my medication and monitoring.

If you do not feel able to help then please give me your decision in writing with your clear reasons for not providing this support to me.

Yours sincerely

You can download a copy of the letter here.