GPs will no longer be able to refer young people directly into waiting lists for children gender services, NHS England has decided.
Referrals may only be made by paediatric or mental health services, and ‘will not be accepted from any other source’, according to new documents published as part of NHS England’s plans to implement the Cass review.
However, GPs will ‘maintain a key role’ in referring into secondary care to consider a referral to a specialised gender incongruence service.
NHS England said that the proposal was supported by the RCGP and by Royal College of Paediatrics and Child Health, and is line with the recommendations of the final Cass Report.
‘Too often in the past referrals were made to the former Gender Identity Development Service by primary care or other professionals, and third sector organisations, of children and young people whose significant mental and physical health needs were not addressed while they remained on the waiting list for GIDS – around 70% of referrals to the NHS Children and Young People’s Gender Service are made by GPs,’ the commissioner said.
The new arrangement will come into effect from 1 September ‘to allow time for NHS secondary care services to adjust their operating protocols’.
As ‘an immediate measure’ up to 31 August, referrals to the waiting list will only be accepted from clinicians working in services that are commissioned by the NHS (primary or secondary care).
An RCGP spokesperson said: ‘We acknowledge that NHS paediatric services and mental health services are working under considerable pressures, but we believe they are most appropriate to make referrals of children and young people to specialist gender clinics.
‘This is in line with recommendations made in the Cass Review and will mean that children and young people, who may have complex and co-existing mental and physical health conditions, can be supported by appropriate specialists and receive the best possible holistic and personalised care.’
It comes after the BMA called for a pause to the implementation of the review’s recommendations, following ‘concerns’ voiced by doctors and academics.
NHS England also said that young people who ‘age out’ of waiting lists for children gender services should seek advice from their GP on whether a referral to an adult gender dysphoria clinic is appropriate.
This is because GPs are ‘better placed’ to support young people considering a referral.
When a young person who is on the waiting list reaches 17 years and 9 months and will not be seen by the time of their 18th birthday, they will be removed from the waiting list and advised to discuss with their GP whether a referral should be made to an NHS gender dysphoria clinic for adults.
It has decided that is ‘not clinically appropriate’ to directly transfer a young person onto the waiting list of an adult GDC because it has ‘no direct knowledge’ of the ‘aims and intentions’ of the patient and that these ‘may have changed while they were on the waiting list’.
NHS England has stopped its previous practice of removing individuals from the 17th birthday in response to the findings of the Cass Review, it said.
And a separate review of the service specification for adult gender dysphoria services in 2024/25 will consider extending the age threshold for access into the adult gender service from 17 to 18 years of age.
What has NHS England decided?
As an outcome of public consultation, informed by the report of the Independent Review, NHS England has decided that:
- Referrals must be made by NHS paediatric services or NHS mental health services for children and young people. Referrals will not be accepted from any other source including primary care.
- There will not be a minimum age threshold, in line with Recommendation 4 of the Cass Report (April 2024) that says that when families/carers are making decisions about social transition of pre-pubertal children, NHS services should ensure that they can be seen “as early as possible” by a clinical professional with relevant experience.
- Referrals to the waiting list for the Children and Young People’s Gender Service will be accepted for individuals up to the age of the 18th birthday.
- Individuals will be routinely removed from the waiting list for the Children and Young People’s Gender Service once they reach the age of 17 years and 9 months.
- NHS England will maintain the approach of advising individuals who ‘age out’ from the waiting list, to seek advice from their GP on the appropriateness of a referral to an adult Gender Dysphoria Clinic (GDC).
- A new referral consultation service will be offered by the providers of Children and Young People’s Gender Services.
Source: NHS England
The commissioner also announced yesterday that:
- Up to six new specialist centres will be rolled out by 2026 to provide ‘tailored’ gender services for children and young people;
- Each of the new services will have ‘a nominated paediatrician or psychiatrist’ who has ‘overall clinical responsibility’ for patient safety within the service;
- The next new service in Bristol will become operational by November 2024;
- There are plans to mobilise a service for the East of England over the course of the next year.
- Subject to academic approval, recruitment to a clinical trial into the potential benefits and harms of puberty suppressing hormones for children and young people is likely to commence in early 2025
The plans are based on recommendations from the Cass Review, which called for a more ‘holistic and personal’ approach with gender services matching the standards of care and research expected from other parts of the NHS.
‘Young people referred into the service will have their wider health and care needs considered and assessed holistically,’ the commissioner added.
NHS England wrote to Dr Cass giving an update on the implementation of her recommendations, and said that it will conduct a review into the operation of the commissioned adult gender services.
This review, led by Lancashire and Cumbria ICB medical director Dr David Levy, will:
- Assess the ‘quality and stability’ of each service, and whether the existing service model is ‘still appropriate’ for the patients it is caring for;
- Consider experiences, feedback and outcomes from clinicians and patients, with first onsite visits scheduled to start next month;
- Be supported by a panel of experts, patients and stakeholders, including representatives from the CQC, Royal Colleges and professional bodies.
The findings of this review will inform an updated adult gender service specification (non-surgical interventions) which will then be subject to engagement and public consultation.
NHS England’s medical director for specialised commissioning Professor James Palmer said: ‘The Cass Review is the backbone on which our implementation plan is based. It’s clear that our services for adults need focus too.
‘The waiting times for care are too long and experiences of care are too variable. The review needs to address poor experience but also learn from good experiences of care.
‘There remains considerable work to do, but we are already making progress on a number of Dr Cass’ recommendations, and our plans published today set how we will establish services that provide the care that patients and their families need to thrive.’
Health secretary Wes Streeting said: ‘I am pleased to be working with NHS England to fully implement the recommendations from Dr Cass’s review, so that young people get the safe, holistic care and support they need.
‘The unacceptable waiting times for gender services cause enormous distress to children and young people, at a crucial point in their lives.
‘As well as rolling out new services, NHS England is setting up a clinical trial to establish the evidence on puberty blockers, because children’s healthcare should always be led by evidence.
‘I want trans people in our country to feel safe, accepted, and able to live with freedom and dignity.’
Responding to the plans, BMA chair of council Prof Phil Banfield said: ‘Service provision is severely lacking for transgender children and young people. The BMA is deeply concerned about the Government’s selective ban on puberty blockers, and we hope the announcement of the start of clinical trials will provide some reassurance to these patients.
‘As the Cass Review states, for some the best outcome will be transition, and we hope that today’s announcement will be part of a wider and concerted effort to address the current obstacles to care.
‘Nevertheless, concerns have been raised with us about the extent to which the Cass Review recommendations can meaningfully improve these patient’s lives. We remain committed to carrying out an evidence-led evaluation of the Cass Review.’
NHS Providers deputy chief executive Saffron Cordery said the plan provides ‘important clarity’ for the children and young people and families who need care and support.
She said: ‘The specialist regional centres and changes to the referrals process announced today will play a critical role in helping trusts deliver holistic, therapeutic and evidence-based care, which best supports the gender identity needs of children and young people.
‘Similarly, trusts will welcome further clarification regarding the national coordination of services, in clinical research and policy, and in workforce training and education.’
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Good. There’s been ongoing failure of leadership on this topic where default was “GP to do”. Time to introduce more scrutiny and safeguards to some irreversible acts,and harms,
BMA, sorry, not with you here
Given that Paediatrics won’t be interested, whilst CAMHS routinely reject all GP referrals, I suspect these patients will boomerang back on us.