Tavistock inspection

The Gender Identity Development Service has been inspected and called inadequate. However, much of the inadequacy relates to insufficient funding, staffing and support from other health services. There is no evidence that anyone has been referred for puberty blockers or cross sex hormones who should not have been.

The headlines seem damning. Leadership, and the service’s responsiveness to people’s needs, are “Inadequate”, the lowest setting. Safety and effectiveness “require improvement”. Only the heading of “caring” is good.

The Care Quality Commission (CQC) report is written as continuous prose, but much of it is a response to tickboxes, and this is clear from the writing. For example,

The provider had a policy on the Mental Capacity Act. Staff were aware of the policy and had access to it. Staff knew where to get advice from within the provider regarding the Mental Capacity Act. When staff had any concerns about a patient’s competency or capacity, they could discuss the matter with senior colleagues at the complex cases panel.

Here there are four sentences, copied mostly or entirely from a checklist, where “yes” has been ticked. It may be easier and cheaper for inspectors to work in this way, but certain nuances will be missed. Often, I want further information.

In October 2020, the service was working with 2093 young people, and there were over 4,600 on the waiting list. Some young people waited over two years for their first appointment. This is clearly an issue of funding and staffing, which produces problems managers cannot solve. Considering there are 11m children in England and Wales, that is 0.06% of the population, less than the proportion of trans people transitioning: so many trans children are not even referred. A tiny fraction of that number is referred for puberty blockers or hormones: from the Keira Bell case, in the year 2019/20 only 161 children were referred for puberty blockers.

The service employed 66.3 clinical psychologists and psychotherapists, 6.6 assistant psychologists, 1.8 consultant psychiatrists, 1.8 specialist nurses and 15 administrators. There were vacancies for 9.2 psychologists or psychotherapists, six administrators and three assistant psychologists, and staff turnover was 23.5%, which is similar to the total turnover for the trust, which provides adult and child mental health services for several London boroughs. The sickness rate of 2.19% was less than the Trust’s, which was 2.5%. This shows the pressure on mental health services.

Safety

Calling the service unsafe because it has long waiting lists is unfair to the staff. Many of those 6,700 young people were very vulnerable and at risk of self-harm. The size of the waiting list meant that staff could not proactively monitor the risks to all patients waiting for their first appointment. Where patients were particularly high risk, staff worked with local mental health services and social care to keep children safe. When things went wrong, managers investigated and shared lessons learned.

Staff were working with high caseloads- around fifty young people each, but one had a caseload over 100. They could refer urgently to a psychiatrist when necessary.

Where training was insufficient, it is not relevant to gender identity. Only 74% had had mandatory training on “preventing radicalisation”, and 54% on adult basic life support. The most relevant training, such as safeguarding children level 3, was 95%.

Where a child is at risk, there are protocols requiring a risk assessment completed jointly with local Children and Young People’s Mental Health Services (CYPMHS). Staff identified many patients at risk- young people who had made suicide attempts or were vulnerable to sexual exploitation. GPs, local CYPMHS, social services and school special needs co-ordinators should work together on risks. The report says, “The service did not have the resources to sufficiently address risks associated with gender dysphoria of young people on the waiting list”. Some work with families involved supporting vulnerable adults at risk of abuse.

Recorded “incidents” threatening safety included a member of the public posting abusive messages about the service on social media, and another leaving an abusive voicemail message. One young person took an overdose of over-the-counter medication after their therapeutic session evoked traumatic memories.

Effectiveness

The service requires improvement because staff assessment of patients were “unstructured, inconsistent and poorly recorded”.

Staff took great care if there was to be an endocrinology referral. “The decision to refer young people to endocrine clinics was taken by at least two clinicians and reviewed at a meeting of senior staff”. If staff were hostile to such referrals, they may not have sufficient supervision.

In April 2019, five staff quit, and were reported in the right-wing, anti-trans press- Mail, Times, Spectator- as “whistleblowers”, opposing referral to endocrinology. Such a view only makes sense if you believe such referrals are always wrong. It fits with an older view of cross-gender identity as a “disorder”, to be corrected, rather than a healthy matter of identity. One staff member had failed to provide handover notes. Perhaps this was one of the “whistleblowers”.

There was good practice in applying the Mental Capacity Act, which applies to people over 16, where people are believed to be capable of consenting to medical treatment unless demonstrated not to be. In January 2020 there was a standard operating procedure for consent, capacity and competency. Sometimes, before then, there was no evidence of an assessment of capacity, which may have simply appeared complete. After, there was a checklist showing the young people had the ability to understand, retain, and weigh up information, and communicate their views. The service audited itself in March and September 2020 to ensure it kept to its strengthened rules.

The report says that the records did not sufficiently record the needs of patients with autistic spectrum disorders. It makes no recommendation on what to do about this, no opinion whether autistic people are more likely to have a different gender identity, and there is no reason to doubt a child’s gender identity simply because they have an autism diagnosis. Staff had training on autism.

Caring

The service is caring, and the CQC rated this “Good”. Staff treat patients with compassion and kindness. “They understood the individual needs of young people and supported young people to understand and manage their care, treatment or condition”- surely that is the most important measure of effectiveness or worth of a clinical service. Staff involved young people, and were appropriate families and carers, in assessment, treatment and care.

Responsiveness

Responsiveness is rated “inadequate” because the service does not have the staff or funding to provide a proper service. The main reason for the rating was the long waiting list.

Staff did not always record ethnicity data, or other potential grounds for discrimination.

33% of young people only attend one session. This may indicate that the referral was questionable, and that the child would not benefit from a gender clinic. I would love to know why. Perhaps one session was sufficient to allow the child to be happily gender non-conforming without further intervention. I would view that as a success, and I hope all but the worst transphobes would too: it shows that not all referrals are trans children needing treatment.

The service made adjustments for physical disability.

Leadership

Leadership was found to be inadequate. Leaders had a good understanding of the patients, and staff understood the GIDS’ vision and values. Young people said the staff showed those values.

The problem was in making improvement when needs were identified. Leaders had a good understanding of the services and its challenges, including the “high levels of external scrutiny” (attacks from transphobes). “The values and ethos of the service focused on promoting non-judgemental acceptance of gender identities, taking a holistic approach and providing support to both young people and their families.” That in itself is enough for the transphobes to attack.

Colleagues had collaborative and supportive relations, and felt proud of the way the service supported the young people. There was a sense of being under siege from external pressures.

In March 2019 the service wrote a comprehensive action plan to improve service performance. It recommended 55 specific actions. The CQC criticised this, though some inconsistencies may be explained by patient need. For example patients received between one and 25 sessions, and some patients had more than fifty sessions. Perhaps this was giving necessary ongoing support.

The service had well-established, supportive arrangements on transferring patients to adult services.

The service is poor because the waiting lists are too long. This means that children and young people who need puberty-blockers or cross-sex hormones are not getting them.

The report is available here.

The CQC press release headlined the need for shorter waiting times. The release said there were concerns relating to safeguarding, without specifying that these related to adult safeguarding in a service for young people.

There is a separate NHS review, which is yet to report.

The Tavistock and Portman NHS Trust provides mental health services for several London boroughs, the national gender identity development service (GIDS) for people under 18, and the Charing Cross adult gender identity clinic. In 2018 the Care Quality Commission (CQC) inspected the trust.

The adult GIC “required improvement” in 2016, because it breached regulations on good governance:

Administrative systems caused problems for people who used the service. There were long delays between people being referred to the service and having an assessment and treatment. There was no formal engagement strategy with people who used the service. Some people who used the service did not know how to complain. There was a disconnect between the (previous) trust and team working in the service. There was no evidence of learning from complaints and incidents.

It was rated “good” as safe, effective, caring and responsive. In 2018, the CQC found that governance had improved. Staff were happier and the service had a low staff sickness and vacancy rate. But at the time, people were waiting 13 months from referral from a local psychiatrist for the initial assessment. There were 53 complaints in six months.

In 2018, the service was Outstanding on effectiveness, because it undertook research and participated in international conferences to improve best practice.

The GIDS was rated “Good” for all key questions in 2016, and not inspected in 2018.

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