Governing Body Meetings

For those questions asked at a Governing Body meeting where a full response could not be provided at the time, please find the question and full response below.

Governing Body meeting – 17 March 2021

Question – In January 2020, the BBC reported that many trans people were having to wait up to 3 years for their first appointment, due in part to a 40% increase in referrals as more trans people feel empowered to seek treatment. The NHS has increased funding and yet there still remain many patients on the waiting list.

One solution to this for those who have the available funds is shared care, in which a patient can be seen by a private healthcare facility, and the prescriptions processed by the local GP. The Dorset CCG shared care guidelines for drug/and or indications states that the GP must be confident to prescribe the necessary medicines. In practice, this means that trans people in Dorset have to call every GP surgery in the area and ask them if they feel comfortable with shared care. From personal experience, GPS have erred on the side of caution and said they do not feel comfortable. This is an unnecessary barrier between trans people and the care they require, and costs them precious time and additional emotional labour, as trans people face the concurrent worry of whether their GP has experience working with gender dysphoria and will be receptive.

I would like to ask why there is no central document which shows which GPs are comfortable with shared care? The administration would be easy; an email once a year to doctors surgeries, responses collated and placed on the CCG website. A disclaimer to advise that the list is not live and details are only updated annually. This small administrative task would make a huge difference to trans people, and I am happy to volunteer my time to help collate this information or aid the task in any way I can.

Response – The NHS Dorset CCG developed a shared care guidance template which is used across a range of services where patients are receiving shared care between their hospital consultant and their GP, and when care is being transferred to their GP from their hospital consultant.  These shared care guidelines support the implementation of the NHS England guidance on ‘Responsibility for Prescribing between Primary and Secondary / Tertiary Care 2018.’  This document provides the framework to support the specialist clinician and the GP in prescribing the agreed medication whilst the patient is moving between the services or supported by both.

There are multiple requirements for shared care arrangements to take place, such as the service being commissioned for shared care.  It is based on the clinically agreed national guidance, the medication being available on a GP prescription (FP10) and GPs feeling competent to prescribe the necessary specialist medication, amongst others.

The gender dysphoria services are specialist services and commissioned by NHS England directly.  In 2018 NHS England established a Gender Dysphoria Programme Board responsible for leading the future delivery and configuration of specialised services for people with gender dysphoria across England.  The Clinical Reference Group (CRG) provides independent expert advice to the Programme Board on the various aspects of the Board’s work. Since the Programme Board was set up, it has:

• Developed two new service specifications for adult services, that were agreed as an outcome of extensive stakeholder engagement and public consultation.
• – Gender identity services for adults; non-surgical interventions
• – Gender identity services for adults; surgical interventions
• Overseen the process of awarding contracts for the provision of specialised services for adults (surgical and non-surgical) through a process of competitive procurement.
• Developed the framework for the establishment of new gender dysphoria services in primary care and sexual health services, as pilots for evaluation, in London, Greater Manchester and Cheshire and Merseyside.
• Established a national referral support service to assist individuals in choosing a surgical provider that can best meet their objectives; the next phase of this work will involve establishing a new quality framework that requires designated surgical providers to report meaningful clinical indicators, and that includes patient reported outcome and experience measures (to be co-designed with people with lived experience).
• Undertaken a full independent review of the gender identity development services for children and young people service specification and clinical commissioning policy during 2020-21.

The two new service specifications mentioned above do not yet include any recommendation or agreement of shared care arrangements for gender dysphoria, however, the non-surgical interventions specification does mention that future versions of the specification will describe that a shared care arrangement could be considered for prescribing and monitoring of endocrine treatments.

For information, further information on the Gender Dysphoria NHS England programme can be found here: https://www.england.nhs.uk/commissioning/spec-services/npc-crg/gender-dysphoria-clinical-programme/

As stated in paragraph 3 of this response, one of the requirements for a shared care arrangement to be undertaken by GPs is for it to be commissioned and at present, a shared care model for gender dysphoria services is not yet supported by NHS England who are the service commissioners.  Without the support from NHS England in recommending and commissioning shared care, NHS Dorset CCG is unable to work with our local GPs to implement such an arrangement.  If this changes in the future, we are already supporting several shared care pathways through our local policies and would hope to be able to support Dorset GPs to add that shared care arrangement to offer to our local patients where possible.

I understand this does not provide a positive response to your question or impact the very important point you raise around saving an individual additional emotional labour and precious time.  I am very sorry that at this point we are unable to do this for you and would like to thank you for your kind offer of support should we have been able to offer gender dysphoria service shared care in Dorset.