A GP practice which served notice on providing gender dysphoria medication and monitoring has faced a push-back from its ICB, despite the service not being contractual.
In December Jubilee Medical Partnership, which runs two surgeries in Nottinghamshire, told its patients it cannot continue to provide gender dysphoria care beyond April.
The practice served notice on the service emboldened by collective action but also on grounds of clinical responsibility and expertise in this area, according to the local LMC.
It explained to its patients that this work has not been funded as a national or local enhanced service and is ‘more appropriately’ provided by a specialist as it is ‘beyond the clinical expertise and knowledge’ of GPs to provide this service ‘in the way that it should be provided’.
This prompted a patient protest in front of one of the practice’s sites, organised by campaigning group Nottingham Against Transphobia, at the end of last month.
Now Nottingham and Nottinghamshire ICB has told Pulse that it has asked the practice to continue to provide care to transgender patients until the conclusion of a ‘comprehensive’ review into shared care protocols, which will cover gender dysphoria.
But the local LMC said that the ICB ‘cannot force them’ to continue providing the service past April, and that it is ‘irresponsible’ to ‘ignore’ the fact that many GPs do not feel safe to do so.
A spokesperson from the ICB told Pulse: ‘All NHS providers should provide equitable support for all population groups in line with the Public Sector Equality Duty (PSED) under the Equality Act 2010.
‘The ICB is asking that the practice continues to provide care to these patients until the conclusion of a comprehensive ICB-led review into shared care protocols, which will cover gender dysphoria. We have offered to facilitate training to support the practice to deliver this care safely.’
Nottinghamshire LMC told Pulse that the ICB’s ‘tone’ has been ‘disappointing’, particularly when they have previously acknowledged the contractual position and lack of a ‘satisfactorily’ commissioned service.
The LMC’s chief executive Michael Wright told Pulse: ‘We’ve advised the practice that this work is not contractual and that the ICB cannot force them to continue providing the service past April.
‘This is not appropriately commissioned work, many GPs will not do it because it is not contractual and because they lack expertise in supporting such patients with this.
‘The locally-based gender identity clinic, GMC, ICB and area prescribing committee are pointing out that GPs “can” provide this service, not that they must and this is confusing patients.
‘It is irresponsible to say this and rely on the goodwill of GPs to do it and to ignore the fact that many do not feel safe to do so.’
He added that RCGP and BMA guidance supports the stance that the LMC and the practice are taking, and that the BMA has asked for an appropriately commissioned service for years.
He said: ‘We want a properly supported and commissioned service to be made available to all Notts patients, it is a postcode lottery as to which practices do and do not provide it currently.’
Mr Wright said that the LMC is working with the ICB towards them commissioning a service to enable those that want to carry out the prescribing work to continue to do so ‘at scale’ so that all patients can access the support from a GP ‘who is contracted and confident in doing this’.
‘Should the ICB come up with a service that takes a few weeks past the April deadline to implement then we may suggest that the practice keeps providing it but only for a very limited time, we hope that this will not be necessary,’ he added.
Pulse has contacted the practice for comment.
The practice had previously said it was working with local gender identity clinics and the ICB to ‘minimise disruption’.
In a statement on Facebook, it said: ‘Unfortunately, these clinics cannot keep pace with the growing demand for these services and the average waiting times are currently more than three years.
‘As GPs, we feel this is an unacceptable level of service, and we continue to campaign for more equitable care for the transgender community.
‘This would involve not only more timely access to specialist care, but also continued resources to fund and train GPs to maintain prescribing and monitoring.’
Nottingham GP Dr Irfan Malik, who is a partner at Elmswood Surgery, told Pulse that moving forward it would be more appropriate for a specialist to provide the service, as it is ‘beyond the clinical scope of GPs’.
He said: ‘Our GP surgery continues to prescribe hormone therapy for patients with gender dysphoria.
‘However this service is not part of the GP contract, it is not commissioned by the ICB or any enhanced service.
‘Moving forward it would be more appropriate for a specialist to provide this service, as it is beyond the clinical scope of GPs. This would provide an increased level of care for patients.’
It comes as practices around the country have served notice to their ICBs on ‘unfunded work’ as part of collective action organised by the BMA.
BMA GP committee chair Dr Katie Bramall-Stainer said: ‘Patients should never have to resort to self-medicating due to gaps in service and commissioning, but trans care is a specialist service, not commissioned from general practices.
‘Trans patients, being a particularly vulnerable group, require urgent action around safe and appropriate commissioning arrangements.
‘We urge NHS England to ensure that such services are available in future service specifications, so that trans patients can access the care they need.’
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As a GP, I ‘can’ anaesthetise a patient and remove an appendix, (and even claim a minor surgery fee, possibkly), but I would not, I would refer the patient with suspected acute appendicits to a specialist abdominal surgeon and a consultant anaesthetist and ward nursing team in a hospital.
Equitable provision to patients with gender dysphoria is that I would be prepared to treat their ordinary general practice needs, and refer them to a specialist in secondary care services for full assessment by appropriate specialist team in secondary care – I would not attempt to treat them for something beyond my capabilities.
I might assist a supervising specialist, but if the ICB is not providing a suitable specialist to do the supervision, in a way that supports safe care, I would not, just the same as I will not treat dental abcesses or pull teeth, or ‘cut for the stone’.
For too long the authorities haven’t commissioned services in the knowledge that GPs will do it for free in face of patient pressure.
ICB providing poor quality care through dumping specialist services onto overworked and overwhelmed primary care services as they think they can get the service delivered for free under the good will of GPs wanting to help their patients,knowing their is a block contract in primary care.
Time to stand up for patients and demand high quality specialist care provision for vulnerable patients
This is not about money, this is Specialist prescribing outside a GP expertise.
The moral of this story is do not take on any work that you are neither contracted nor paid nor fully qualified for ; ” for the benefit of your patients”. It will likely end in one of three ways at some point:
You will be out of pocket, threatened with legal action when something goes wrong or facing the wrath of your patients and their various pressure groups when you no longer have the capacity to keep providing the service.
Wakey wakey! The road to hell is paved with good intentions
The GMC are part of the problem here. In 2016 their guidance on this matter put pressure on GPs to prescribe, making an exception to the usual standard of only prescribing within competence. Given GPs cannot learn and internalise all of medicine we have to stratify into: common urgent; uncommon urgent; common non urgent; uncommon non urgent.
Prescribing gender medication is uncommon in a GP population and non urgent so really should be under a specialised service. If commissioners haven’t sorted this out for the past decade they can’t suddenly get upset when a Gp stops prescribing.
Of course it doesn’t help that the gender prescribing advocates are disingenuous – in this publication articles trying to appropriate the well understood treatment ‘hormone replacement therapy’ in relation to gender prescribing have been published, and incorrect information around suicide rates and prevalence of ambiguous genitalia are presented as facts.
We (the medical profession) are part of the problem here, but unfortunately the UK’s system of specialist to advise, Gp to prescribe, provides a responsibility gap where GPs have to justify not prescribing rather than simply state ‘no I don’t want to – you do it if you feel it’s important’.
This is what the GMC said in 2016, note the use of ‘must’ at that time:
““You must co-operate with Gender Identity Clinics and gender specialists in the same way that you would co-operate with other specialists, collaborating with them to provide effective and timely treatment for trans and non-binary people. This includes: prescribing medicines recommended by a gender specialist for the treatment of gender dysphoria; following recommendations for safety and treatment monitoring; making referrals to NHS services that have been recommended by a specialist.
Once the patient has been discharged by a Gender Identity Clinic or gender specialist, the prescribing and monitoring of hormone therapy can be carried out successfully in primary care without further specialist input. From the patient’s perspective, management in primary care is far easier, and there is no specific expertise necessary to prescribe for and monitor patients on hormone therapy.
It is not necessary to refer trans people back to their gender specialist before referring them to other secondary or tertiary providers, for matters unrelated to their gender history.
If you feel you lack knowledge about the healthcare needs of trans people, you should, in the short term, ask for advice from a gender specialist. In the longer term, you should address your learning need as a part of your continuing professional development … which will enable you to provide treatment to meet your patients’ needs. E-learning is freely available on the Royal College of General Practitioners’ website and carries CPD points”.”
Essentially it said do it regardless of if you believe it is appropriate and whether you are commissioned to do it. If you don’t have the competencies you must proritise becoming sufficiently expert in this experimental field of medical intervention.
Later guidance isn’t so forceful but it is a problem – does the ‘just following order’ work for GPs when we ‘must’ do whatever specialists decide, even if we disagree? And can we disagree on the basis of ‘not comfortable but don’t have the inclination to learn enough to say no’ as that is a unilateral time theft if you have to become an expert to decline taking on expert care!
The fact that the NHS decided it would offer prescription based solutions to gender dysphoria does not mean this is Primary General Medical Care. And nor does the lack of meaningful Specialist service provision to meet the demand make GPs Specialists qualified or obliged to offer to take this on.
The transgender rights movement fought long and hard to rightly gain public acceptance that believing you are a different gender to your biological sex is NOT A MENTAL ILLNESS.
NOT ILLNESS = NOT GMS = NOT MY JOB
Remind the ICB this is not a negotation. No is a complete sentences. don’t hand back anything that is not in your contract anyway. just don’t do it. I hope you can now leave it to the LMC and BMA to fight your corner and get on with the day job of being a jobbing GP.