The Academy of Medical Royal Colleges has been called on to rescue the opening of two new NHS gender identity services for children and young people.
By Hannah Barnes https://www.newstatesman.com/politics/2024/01/inside-nhs-englands-faltering-plan-to-replace-tavistock
The NHS’s once flagship children’s gender clinic – the Gender Identity Development Service, or Gids, based at London’s Tavistock and Portman NHS Foundation Trust – has been earmarked for closure since July 2022. The decision followed a Care Quality Commission report that rated the service inadequate, and the interim findings of an independent review led by the paediatrician Hilary Cass of children’s gender identity services. Gids was supposed to have been shut by spring 2023, replaced by the first two of several regional hubs, operating under a different, more holistic model of care: less medical, more therapeutic. But these new services have been beset by delays. The spring opening didn’t happen. Another target, to have the London-based service open by autumn last year, also came and went.
Now, the Academy of Medical Royal Colleges (AMRC) has been called on to try to rescue the opening planned for April this year. Great Ormond Street Hospital (Gosh), one of the hospitals that will run the new London-based service, was responsible for developing key training materials, but has been unable to produce them on time. The material, which a team of ten was employed to work on from last spring, was meant to have been finalised months ago, but it’s understood the group could not agree on the content. A planned training day for new staff was cancelled in October 2023 with just a day’s notice.
Gosh will play no further role in training going forward, with that responsibility being taken over by the AMRC. NHS England has asked the AMRC to put together an induction course for staff recruited to the services. It will provide an overview of the key issues they are likely to face when working with young people struggling with their gender identity. The work “won’t replace the in-depth training programme”, a spokesperson from the AMRC confirmed – there isn’t enough time – but will “ensure clinicians are confident and have access to the right resources to begin seeing patients”. “Our members are keen to help ensure this service can go live as planned,” they added, “[as] it’s really important these children and young people are seen and treated in a way that’s right for them.” Gosh confirmed the education programme has been passed to AMRC, adding that its team had “wrapped up its part of the process having produced a range of high-quality materials”.
In her interim findings, Hilary Cass said the Tavistock being the sole provider of specialist care for the whole of England was “not a safe or viable long-term option”. While she refrained from criticising individuals, she found the model of care they were operating under wanting. Cass called for a “fundamentally different” approach under which young people’s other difficulties are considered alongside their gender-related distress, and different children could receive different treatments. The NHS plans that puberty blockers, a referral for which was routine practice at Gids, will only be made available as part of a clinical research trial or in exceptional cases. Initially there will be two new regional gender services, in London and the north-west, with more planned across England to open later in the year.
In the decade or so before the Cass Review began in 2020, referrals to Gids rose considerably – from 97 in 2009-10 to 2,750 in 2019-20. The service couldn’t cope with the sheer numbers, and the complex lives of many of the young people coming through its doors made the task even more difficult. Staff at the clinic raised serious concerns that the way the service was operating wasn’t always safe: that children were sometimes being referred for puberty-blocking drugs without other difficulties in their lives being explored adequately first; and that the evidence base underpinning that treatment was weak and not always properly communicated to families.
With the news that training materials have not even been written yet, an April 2024 opening – or at least a service operating at anything like full capacity – seems doubtful. As the AMRC put it, “time is tight”. Job adverts for roles in the new services only closed last week. It’s another blow for the 6,000 or so children and young people facing gender-related difficulties on the waiting list. According to internal documents, Gids hasn’t removed anyone from the list since October 2022. In the meantime, it continues to grow.
For those who have followed this story closely, it will not come as a surprise that Great Ormond Street has been unable to complete the task on time. It was always going to be difficult; no one questions that. NHS England was first notified of serious concerns about Gids in at least 2018. The failure to act sooner has undoubtedly made the task of fixing the system harder. But it was made almost impossible by Gosh’s wish to “recruit a wide range of people” to crucial education and training roles. That may sound sensible, but in practice it led to a bizarre situation. Of the team recruited to work on the training materials close to a year ago, several had stated their opposition to aspects of the Cass Review’s interim findings, or held views on how to work with gender dysphoric children that appeared incompatible with the approach recommended by the review.
One was a current senior clinician at Gids who, according to the BBC, described themselves as being “devoted” to taking an affirmative approach to working with young people. There is disagreement on what “affirmative” means, with Gids insisting that it doesn’t preclude exploring other aspects of a child’s life. But Cass’s interim review noted the service at the Tavistock appeared reliant on “predominantly an affirmative, non-exploratory approach”. Another person recruited had openly questioned Cass and NHS England’s more cautious stance on social transition (where a young person changes their name, pronouns and way they dress) on their public blog. And a third member of the team, the clinical lead for Gids and consultant endocrinologist, Gary Butler, gave a speech questioning the need for any change to the Gids approach and appearing to accuse Cass of “nepotism”.
I reported on this last spring for BBC Newsnight, and approached Gosh, NHS England and the government for comment. No one was prevented from starting their posts, despite pre-employment checks still being under way at the time. Instead, these institutions insisted that whatever the make-up of the team, the training materials, along with all aspects of the new gender services, would at all times be underpinned by the findings and recommendations of the Cass Review. Butler said reporting of his comments had been “highly selective” and that he fully supported Cass’s recommendations.
The desire to recruit people with different views ultimately led to placing Gids whistleblowers – those who had repeatedly raised concerns about the safety of the service and the clinical model it was operating under – alongside those they had either blown the whistle on, or who were still working under a system they had roundly criticised. It could never work. The team manager’s resignation in October 2023 was quickly followed by others. LinkedIn profiles confirm that several other members of the team stopped working at Gosh in December.
Even before anyone was handed a job, startling decisions were made. Some applicants were told that Polly Carmichael, who has been in charge of Gids since 2009, would be on the interviewing panel. For some, the last time they had seen Carmichael was in an employment tribunal, testifying against her and the Tavistock Trust. (The judge in that case concluded that Carmichael had communicated to Gids staff not to seek external safeguarding advice.) In the event, Carmichael did not take part in interviews, but it was a bad start. At best, the consideration was naive, at worst, wilfully ignorant.
The Academy of Medical Royal Colleges now has a Herculean task ahead to produce the materials in time. NHS England’s official position remains that the first two new services will be fully mobilised in April. But given no training of staff has taken place, and that the content of that training hasn’t even been written yet, it seems highly unlikely. Another option might be that a small number of staff are trained initially, with capacity gradually built up. Young people have been badly let down by the NHS. But there will not be another opportunity to get youth gender services right. If that takes a few more months, maybe the short-term pain will be worthwhile.