New NHS gender clinics for young people understaffed and not ready, say sources

The new NHS gender identity clinics for young people are “nowhere near ready”, “understaffed”, and employing inexperienced clinicians who don’t have a finished treatment protocol in place, according to whistle-blowers who spoke to i.

Two new hubs, one in London and one in the northwest, will begin seeing patients this week, to replace the Gender Identity Development Service (GIDS) at the Tavistock and Portman NHS Foundation Trust. But senior staff at GIDS have expressed concerns about the preparedness and expertise of these hubs – and today are raising the alarm about the implications for patients.

“It’s been shoddy, disorganised, messy and unclear. And at times, it’s felt unsafe,” said one of the whistle-blowers, who spoke on the condition of anonymity. “They’re not fully staffed, they’re not fully trained.” It’s like “reinventing the wheel with a square,” said another. “We’re going from a single-service model to a no-service model,” said a third.

In July 2022, NHS England announced the decommissioning of the GIDS clinic, which by then had become one of the most politically debated services in NHS history, had been rated ‘inadequate’ by the Care Quality Commission, and been the subject of an independent review by Dr Hilary Cass which highlighted several concerns. She concluded that the current model was “not sustainable in the longer term”.

In its place, NHS England promised two new centres initially – with several more regional hubs to follow – that would be a more “resilient service by expanding provision and enhancing the focus on quality in terms of clinical effectiveness, safety, and patient experience.”

While work is underway to achieve this, including the opening of multiple hubs and many more staff, NHS England accepts that it is a significant and complex task which is not yet completed. Exact timeframes for completion, including recruitment, remain unclear. The first two hubs are opening a year later than planned, and the clinicians who spoke to i fear even those first clinics are insufficiently prepared to cope with the size and complexity of the cases, or the waiting list.

They claim the handover of patient files has been “last minute” — despite everyone knowing GIDS would close nearly two years ago — and that at one point earlier this year managers asked clinicians to write entirely new patient notes because they couldn’t work out how to transfer the existing files. They are baffled by what they say is an explicable drop in numbers on the waiting list, during a period when no new patients were being seen. And they say that there has been “no clinical oversight” of young people on that list.

“This has been colossal mismanagement by NHS England,” said one whistle-blower, “they need to be held accountable for this mess.”

They say the new clinicians being employed are not specialists in gender treatment, and therefore do not have the experience or expertise necessary to see vulnerable young patients with gender dysphoria. And they are worried that despite the hubs opening this week there is still only an interim treatment plan in place.

NHS England’s aim for the new hubs, informed by the recommendations of Dr Cass, is to provide patients with a broader, more holistic service than what was offered at GIDS, with a “multi-disciplinary integrated approach to assessing and responding to an individual’s needs”. This, according to NHS England, would take into greater account other issues patients might present with and adopt a more exploratory role with patients.

“The clinical approach should be mindful that this may be a transient phase,” according to the interim service specification — a phrase which has concerned some clinicians about the potential philosophy underpinning the new services.

While some who worked for GIDS accept there were problems — particularly due to a lack of resources amid escalating demand ­— and although NHS England is responding to political pressure to rectify any flaws with a new service, clinicians who spoke to i remain worried that vulnerable teenagers won’t be better off, will still face huge waiting times, and won’t be meeting staff who sufficiently understand their situation.

Hormone treatments and puberty blockers will no longer be offered in the new hubs (those already on it will continue with endocrine support being offered externally), except within the context of a trial, which may not begin until next year.

In the meantime, said one GIDS clinician: “They do not have a working protocol. Those are the sets of rules that we work to, in a clinical manner, with the patient group. All they have is a draft protocol, which was published by NHS England a few months ago, and is currently out for consultation.” This document is less than half the length of the existing one for GIDS. “It is completely lacking in any detail,” the clinician said.

It is unclear when a final protocol will be published but it is expected to follow the final Cass review, to incorporate her recommendations. This was due by the end of March 2024, but insiders believe it won’t be published until later this month, after the closure of GIDS.

Staffing levels at the hubs are of particular concern to those who spoke with i. According to one whistle-blower, who has been privy to discussions about recruitment to the new services, “they have 17 or 18 clinical staff in total across both clinics. When GIDS was operating at its peak we had 70-plus clinicians and this service is supposed to be commissioned to increase capacity. [Yet] they have less than a third of the number of clinicians currently – and they’re struggling to recruit people. They’re massively understaffed from the point that they launch.” According to NHS England, the services are still in the process of recruiting staff.

The specialist experience of the new staff forms a further concern to whistle-blowers who have already begun to meet with their replacements. Although the recruits are either generalists or specialists in various parts of paediatric or mental health care, “the majority of the new clinicians have no experience of working in gender with trans youth,” said one.

In recent months, “When we’ve had to do handovers to the staff from the new service, about specific, complex or risky cases, they’ve asked questions that have revealed that they don’t know how to do the assessments,” said another clinician. “They’ve asked us how to do the assessments.”

Another clinician told i that staff at the new services are unhappy that none of the staff from the GIDS service are moving across to the hubs. “They’ve said to me, and I know they’ve said to others, ‘please apply for jobs here’ – because they don’t know what they’re talking about. They haven’t worked in a gender service before.”

This is immediately apparent to those with specialist knowledge, they said.

“You can tell when you’re talking to them about the effects of social transition or the specific gender stuff that is our bread and butter. You can tell that they’re like, ‘Oh s***, I don’t know this, and I’m about to be taking on these cases. I don’t know the basics of how to think about some of this stuff, let alone what state the young people are going to be [in] when they start taking them off the waitlist.’”

Staff at GIDS, they added, typically wouldn’t see patients directly for about six months when they first joined, instead shadowing existing staff, learning and observing. But with the shift to the new hubs, recruits won’t have the opportunity to do this.

None of the current staff at GIDS are being re-employed in the new services. “I don’t think that’s the headline that NHS England want. They want the headline to be, ‘GIDS and its staff have nothing to do with these [new services],” said one member of staff. NHS England confirmed that staff are not being redeployed but did not elaborate further.

One of the key recommendations from the Cass review was to de-centralise, moving from a single service based in London to a set of regional clinics — a principle supported by almost everyone, including GIDS staff.

But in reality, they said, so far there’s been a reduction in regional centres. Although GIDS was housed in London with the main clinic in the capital, there was a regional centre in Leeds with satellite bases in Birmingham, Bristol, and Exeter. From April, however, there will only be one hub outside of London for the time being, run in a partnership between Alder Hey Children’s NHS Foundation Trust in Liverpool and the Royal Manchester Children’s Hospital.

Where previously, families from Devon and Cornwall, for example, could go to the Exeter base, now they will have to travel hundreds of miles to London. “When the closure was announced, some of our families said, ‘Do you think there might be a service in Cornwall?,’” said one clinician. Now, parents are being told that they will have to travel significantly further to London for appointments. “Families are saying, ‘I can’t see how we’re going to get there. What are we going to do? I had a mum in tears saying, ‘They promised this was going to be better, but it’s actually going to be worse.’”

John Stewart, NHSE England’s national director for specialised commissioning, said recently: “Our aim is to establish between seven and eight specialist centres including the north and the south hubs over the next year to two years.”

The greatest concern among the whistle-blowers, however, is how the waiting list has been handled. In 2022, following the announcement that GIDS would close, its waiting list of thousands of young people was handed over to NHS Arden and Greater East Midlands (GEM), a Commissioning Support Unit, which provides external support to various parts of the NHS.

For GIDS staff, the problem was what happened next. NHS Arden and GEM took over the running of the waiting list, but “providing an administrative task only”. For a while, therefore, GIDS staff were still expected to provide clinical oversight of that waiting list, so if there was a young person at high or immediate risk, their case could be flagged to a clinician to intervene or provide some help or support. But there was a flaw to this, the whistle-blowers said.

“They were asking us to have clinical oversight of a waiting list that we don’t hold, without access to the relevant information. That felt unsafe. That was an unacceptable situation.”

Staff raised their concerns internally and repeatedly, they said, but did not receive satisfactory answers and still do not know if anyone now has clinical oversight of the waiting list. When i asked NHS Arden and GEM who has clinical oversight of this waiting list, a spokesperson replied: “This is a question for NHS England. NHS Arden and GEM administers the waiting list on their behalf.”

According to NHS England, clinical “responsibility” for those on the waiting list lies with whoever makes the referral, until they are seen by the new service.

NHS England had promised a “specially convened multi-disciplinary team of children and young people’s mental health professionals and gender dysphoria specialists” to oversee referral notes on the waiting list “to identify cases where children or young people may benefit from additional local support”. One staff member told i there’s “zero evidence of it”.

Another said: “This is not true. Enquiries were regularly being sent from Arden and GEM to GIDS as they didn’t know how to deal with them. We raised this with NHS England as we were being asked to deal with clinical enquiries we knew nothing about and had no access to the referrals.”

During the last 18 months, a further issue has baffled staff: what appeared to be a sizeable drop in the numbers on the waiting list. After the announcement was made in 2022 that GIDS would close, there were roughly 7,000 people on the waiting list, but the current figure being cited is 5,000 — a reduction of 2,000 patients in a period in which, said clinicians, no patients were being removed from the list to be seen by staff, yet more would have been added.

At the point the list was given to NHS Arden and GEM in November 2022, there were around 300 new referrals per month, said staff, so if that continued there would now be roughly 10,000 on the waiting list. Yet it stands at half of that. Some of these will be 17-year-olds who were removed from the youth waiting list and added to the adult services waiting list, but this, they said, would not explain all of that potentially 5,000 drop. NHS England denies that anyone has been removed from the waiting list except those who were over 17, any duplicate names, or those who asked to be removed.

In an email to Tavistock bosses in January, one clinician wrote, “there is no indication that adult services has the capacity to pick up all our 17+s” and cited a further worry that for those on the waiting list held by NHS Arden and GEM there is “no phone number for families to call”.

Before signing off, the clinician concluded, “With 10 weeks to go [before the new services open] these situations and unanswered questions are, in my view, clinically negligent and unsafe. It is also completely at odds with NHSE’s repeated statements that transfer will be safe and seamless and that new services will be safer than existing ones. I had a parent in tears the other day, staying, ‘so when they said it was going to be safe and better, they lied.’ I couldn’t have said it better myself.”

Dr Michael Holland, the CEO of the Tavistock and Portman NHS Foundation Trust, replied, saying, “these are concerns that we share. We are in dialogue with NHSE on these very points as we are extremely worried…”

A spokesperson for Great Ormond Street Hospital for Children NHS Foundation Trust, responsible for the London hub, told i: “We can confirm that the London centre/hub will be opening next week [from April 1].” Alder Hey Children’s NHS Foundation Trust, which is co-managing the northern hub, said: “We can confirm that the North West Hub will open in April as planned.”

In response to all the issues raised by the whistle-blowers, an NHS England spokesperson said: “In line with the Cass Review, NHS England took the decision to close the Tavistock and set up a fundamentally different and improved approach to children and young people’s gender services.

“This transition is a complex piece of work, but this is just the first step in establishing a new model which provides holistic support for children and young people and their families.

“Our focus is on ensuring continuity of care as we establish the new service, and all patients waiting will be offered a local mental health assessment, with extra national resource provided to ensure the best possible support.”

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