Localism

Memorandum from GIRES (LOCO 30)

Proposals to the CLG committee

We propose that local social and psychological support be provided for trans people and their families, in line with equality law, and the government White Paper on the new NHS.

The law

· Those who propose to undergo, are undergoing or have undergone a process (or part of a process) for the purpose of reassigning their sex by changing physiological or other attributes of sex, are protected in the provision of goods and services; those perceived to have the characteristic of gender reassignment; and those associated with people who have the characteristic, are also protected from discrimination by:

– the Equality Act 2010 [1] , and by

– the Human Rights Act, 1998 (Articles 8 and 14) [2]

– European law protects users of health services from experiencing ‘undue’ delay in accessing treatment. [3]

· There will be a "requirement for GP consortia to have a ‘duty to promote equalities.’" [4]

· Present treatment protocols for trans people risk breaching these laws by:

– providing discriminatory treatment; causing

– undue delay, and

– failing to provide adequate holistic, therapeutic support for trans people and their families that is locally accessible.

· Decentralising social and mental health care under the GP consortia provides an opportunity to reassess the delivery of care and support to this marginalized group.

· Although the numbers are still low, 20 per 100,000 (subject to regional variation), the numbers presenting for treatment are doubling every 5 years. Existing tertiary services are already overburdened. If no supplementary provision is available, even longer delays will ensue.

· This will be reflected in the significant deterioration in mental health of many trans people and their family members, frequently resulting in family breakdown.

Proposed local complementary services

In the treatment of trans people it has become customary to follow inflexible protocols and pathways, encompassing primary, secondary and tertiary providers; these pathways are applied to all trans people, regardless of their individual needs and circumstances. This suggests stereotyping, so the protocols are, therefore, discriminatory in their application with regard to some service users. [5]

Some local expertise already exists and a few trans people are benefiting from services delivered in their area. However, many are having to wait for long periods of time to be given appointments, and then are obliged to travel long distances to Gender Identity Clinics, at personal expense or, in some cases, funded by the Local Authority.

The Department of Health’s recent Procurement document invites us to challenge existing service provision, by securing delivery of service that is:

– innovative and

– more cost-effective

It is proposed that a new approach, running in parallel with existing tertiary provision, will be cost effective because it is supplied locally under the auspices of primary care; it will be less stressful and expensive for the service users themselves; it will help to avoid the collateral damage to trans people’s lives and those of their families by providing holistic psychotherapeutic support; and it will be likely to secure better mental health outcomes. Consequently, the ongoing cost to the NHS is likely to be less, and the service users are more likely to be making a contribution in the work place because of associated improvements to their mental health and wellbeing.

"A model for such locally accessed treatment is the Trans Care Project in Vancouver, Canada. When the centralised hospital gender dysphoria programme was closed in 2002, a dispersed community-based model of care was set up. Care for the trans population became the responsibility of clinicians with varying degrees of trans experience out in the community. [6] , [7] , [8] Training was provided where needed.

GP consortia

"GPs are well-placed to design care packages for patients, which should lead to improved health outcomes and tighter financial control". [9]

The establishment of 450 GP consortia provides an opportunity to follow a similar model in the UK. It is not suggested that the existing model involving tertiary Gender Identity Clinics be discontinued, but that complementary services be provided locally that would be used in conjunction with, and perhaps, sometimes instead of, tertiary services. Each consortium may expect to be caring for approximately 45-50 trans service users; there may be around 6-8 new cases a year.

Training of local clinicians and health practitioners

It is proposed that 5 regional two-day training events are undertaken, which one GP and one mental health provider from each consortium attends. This would provide a level of expertise at primary care level which would be capable of initiating local mental health support that would be independent of the ‘gatekeeper’ function currently undertaken by psychiatrists, usually as part of the GIC provision.

"It is quite difficult to develop an authentic therapeutic relationship with a client when the initial diagnostic evaluation casts the clinician in the role of a gatekeeper who controls access to medical treatments.." [10]

The ‘gatekeeper’ has the power to delay or deny treatment, which severely inhibits open and transparent communication with service users, who often feel obliged to present with an acceptable ‘script’, which omits or minimises the real difficulties experienced in their lives. The dual role of the GIC clinicians in providing psychological support, as well as undertaking the ‘gatekeeper’ function is inherently contradictory and less able to provide the therapeutic support needed by service users.

Training would be provided by a mixture of professionals and voluntary groups with expertise in the field. In addition an e-learning package would be developed to assist further training. This would be provided to all consortia.

Three main aims to be met by the local provision of services:

1) psychotherapeutic support for trans people at local level;

2) provision of local support for families of trans people, which is currently unavailable in most GICs;

3) provision of an alternative way of meeting eligibility criterion 3 (Harry Benjamin standards of care) [11] for accessing hormones, by enabling three months psychotherapy.

Mental health and social support for trans people and their families

1) Psychotherapeutic support for trans people themselves is currently not provided by some GICs, and even where it is, it cannot be accessed on a regular basis, partly because GICs don’t have the human resources and, partly, because the travelling involved would be totally impractical.

2) Where family breakdown occurs, outcomes for trans people may be predicted to be less good. [12] An holistic view that has due regard for the trans person’s situation in the family setting, can be very beneficial, by helping families to support their trans family member, and to process their own grief and anger.

3) Also, at the moment, in some GICs, the eligibility criterion for obtaining a prescription of hormones, is a prolonged period of real-life-experience. This involves a complete change of gender role in all circumstances: work, home, on the street, in leisure pursuits without benefit of hormones. This is not possible for all service users and unsafe for many. The alternative offered in the International Harry Benjamin standards of care [13] , is a three month period of psychotherapy. For the reasons outlined above, this option is not offered to many trans people. Such a period of psychotherapy can only usefully be done at local level. The training programme proposed would enable independent counsellors to offer this service in reasonable travelling distance from service users’ homes.

Overcoming delay

GPs, in ‘shared care’ arrangements, currently provide hormone treatment: prescriptions and monitoring, following a diagnosis usually obtained at the GIC. This is typically preceded by an initial ‘differential diagnosis’ by a local psychiatrist to establish that no ‘co-existing psychopathology exists’. This model presupposes that all trans people need to be declared free of psychiatric illness before a further assessment and diagnosis can take place. This presumption means that all trans people are subject to this element in the treatment pathway, regardless of need. This stereotyping creates a barrier to treatment and a delay, neither of which is appropriate in all cases.

The European Court of Justice v NHS (2006) defined the concept of "undue delay" as being delay based on an arbitrary timeframe, rather than a medical decision . The result, in this case, was that the PCT had to repay the costs of the private treatment undertaken by the patient.

Better training for GPs will enable them to make well-documented direct referrals either to GICs or to other gender specialists, in all cases where there are no psychiatric disorders. It also facilitates the development of local expertise in providing psychological support and oversight of the care pathway for trans people.

This ability would also be applicable when access to private care is sought. This may also be commissioned so long as comparable standards of treatment are provided; it is often less expensive than the GIC treatment. This approach is endorsed by the NHS Audit, Information and Advisory Unit’s report, [14] and the British Medical Association [15] and the new NHS approach to health service provision.

October 2010