We have recently learned of cuts to transgender healthcare in Plymouth. There has been no public announcement. No consultation. Public questions to the responsible “Integrated Care Board” [1][4] have not been answered. But we’ve seen a letter [2] confirming local GPs are no longer allowed to perform blood tests or offer prescriptions for Hormone Replacement Therapy under shared care agreements in Plymouth [1]. (This only affects new patients, and at this time we believe those already prescribed HRT will be unaffected)
Update 1: As a result of this article, a short sharp campaign getting people to write into the ICB made them change their tune. Within a few weeks they finally responded to us and clarified that shared care arrangements are indeed allowed in Devon. See their letter about it included at the end of this article. This would be a massive victory and good example of direct action! But unfortunately it was short lived…
Update 2: As of February 2024 we are not aware of anyone who has actually got a shared care agreement in Plymouth. They may exist, we don’t know for sure that the ICB lied. However, we have been informed GPs are now telling their patients that the old rule is back and there is a blanket ban on shared care for trans people in Devon. Once again there was no consultation or announcement for this policy. We’ll post more updates here as and when we get them. At present we are not aware of any new campaign to fight back. If you are up for organising a new campaign, I suggest making contact with SOHS Devon and Not Alone Plymouth for advice and support
They tried the same trick with cuts to ADHD and autism services. No announcement, and silence in response to questions. But we pushed back then, and forced them to bring the services back. We’ll do the same again this time as well.
What are shared care agreements and why do they matter? Waiting lists for trans healthcare in Devon are around a decade long (the last patient they saw was referred in 2016!). That’s for a first appointment with The Laurels Gender Identity Clinic. It could take even longer to actually get prescribed HRT. Under a shared care agreement it’s possible to get a private diagnosis and treatment plan, but have your GP administer expensive blood tests and prescriptions. This half-private, half-NHS way of doing it saves a lot of money and is the only way many working class people can access HRT before they die of old age on a waiting list. That’s what the OneDevon Integrated Care Board has stopped.
Trans people already earn below average, so restricting shared care will effectively block many of us on a lower income from accessing HRT altogether.
Cuts to this lifeline are an attack both on transgender people, and the NHS as a whole. Under the new regime of transphobia in the UK, trans healthcare is slowly being restricted one bit at a time, until there is nothing left. Yesterday, it was making waiting lists so long they may as well not be there. Today, it’s targetting shared care agreements. Tomorrow it will be even more rules and restrictions. Conservative anti-trans activists have made it clear they want to reduce the number of people who transition.
OneDevon ICB attended both Plymouth Pride and Totnes Pride over the summer to “understand how the NHS can be more inclusive”. Just like every public consultation, this proved to be only so much whitewashing. They listen to our concerns, and then do it anyway! For all their partnerships and public appearances they are only interested in improving their image, not improving our care. They pretend to be our allies while taking everything from us. The OneDevon Integrated Care Board, and its chair Dr Sarah Wollaston, are complicit in transphobia.
The other side to this story is austerity. The NHS is being cut to the bone, but it’s not all being cut at once. They start by cutting and privatising services for people they see as vulnerable. Anyone they think will have trouble standing up for themselves. That’s why they stopped ADHD and autism services in Plymouth. They thought they could get away with it. That’s why mental health services, even for children, have been privatised all over England. They came for us first, but who will be next? The OneDevon ICB has a target to cut £138.9 million from healthcare in Devon. That’s in this year alone, on top of the £550+ million already cut and the hospitals already closed by their predecessor, Devon Clinical Commissioning Group. Some of the board members still have “Doctor” in their names, but their job is now to cut, not cure. If we don’t stop them here there is no telling what they will cut next. Eventually there will be no public healthcare left, only private care for those who can afford it.
What is to be done?
One person has already tried writing to the Integrated Care Board with a question for their (online) public meeting in October. The meeting was taken offline due to “technical issues”. [3] A response in writing was promised instead, but this has not happened either. The proper channels don’t seem to be going anywhere. So the next step has to be a public campaign. Please email us on (UPDATE: email no longer monitored, please speak to SOHS Devon or Not Alone Plymouth if you’d like to start a new campaign) so we can put people in touch to form an organising committee. We can’t do this alone!
The first thing will be to put pressure on them and show that a great many of us care about this issue. We are asking groups and individuals to contact the ICB and demand answers. Ask them to reinstate shared care agreements for trans patients. Please be respectful! Remember that the staff answering calls aren’t responsible for the decisions. We are going to win this and we don’t need desperation tactics in order to do so. Call them on 01392 205 205 or email d-ccg.corporateservices@nhs.net
Make no mistake, one way or another we are going to put a stop to this. They tried to cut ADHD and autism services in Plymouth. We stopped them. We will beat them this time as well. So watch this space! We’ll post any updates here and on social media.
As this is part of the broader fight against austerity it’s important we link up with other people. Save Our Hospital Services Devon is an excellent local campaign group. Nurses plan to go on strike soon and will need our support on the picket lines as well. We are stronger together.
What do we want?
We’ve learnt that while resisting austerity, it’s important to never lose sight of what we really want: services better than we’ve ever had, even before the cuts. It’s important to keep discussing this even while we stop them making things worse. As a starting point, how about adult trans healthcare based on informed consent? It’s not perfect, but giving us that option would be an improvement. Hundreds of thousands of cisgendered[1] people already get prescribed HRT by their GP, for example to relieve symptoms of the menopause, or to treat testosterone deficiency. So long as trans people have the capacity to consent and fully understand all of the risks, why should we have to face long waiting lists and interrogation by psychiatrists? The hoops we have to jump through are one reason it takes so long.
Of course, this will be difficult when the NHS today is not run by people with our best interests at heart – people like the corrupt Integrated Care Boards. So more broadly we need a people’s NHS – run by us, for us, near us. Standing up to them and refusing to let them make cutbacks is only the beginning.
If you are a transgender person living in Plymouth and need support, please reach out to the excellent Not Alone Plymouth
Footnotes:
[1] – Glossary:
Hormone Replacement Therapy (HRT) – Transgender people are often prescribed hormones in order to transition to the gender they identify as. For example trans women may be prescribed estrogen, and trans men may be prescribed testosterone. Not every transgender person takes HRT, and not everyone can.
Cisgender (cis) – The opposite of transgender. Someone who identifies with the gender they were assigned at birth.
Integrated Care Board (ICB) – the 42 Integrated Care Boards are responsible for commissioning local NHS services in England. That means they decide what services run, what money they get, and if they are run by the NHS or contracted out to a private company for profit. These replaced the old Clinical Commissioning Groups and have been set up to make it easier to cut and privatise healthcare services. For more about the problems, see: https://sohsdevon.org.uk/2022/06/06/radical-changes-ahead/
[2] – A copy of the letter with personally identifying information removed: http://www.solfed.org.uk/sites/default/files/uploads/nrw-shared-care-refusal.public-noinfo.jpeg
[3] – See their youtube link. We are sure it is only a coincidence that these technical issues resurfaced just before they were scheduled to discuss a response to nurses’ plans for a strike! But we are concerned that the people bringing “virtual beds” to Devon can’t even seem to manage a simple online meeting…
[4] – We have been sent the following public question which was submitted to the ICB on 11/10/2022:
“We understand that there has been a recent change in policy regarding funding for treatment of gender dysphoria in Plymouth. We have seen a letter from one GP, in response to a request to undertake blood tests and prescribing under a shared care arrangement, which states “We have in the last week been advised that our local CCG has not agreed terms for ongoing GP funding of this service, being able to prescribe and monitor bloods […] The situation is now that our local CCG has not agreed funding going forward for management of gender dysphoria within Plymouth and we are therefore not in a position to take on any new cases.”
“Please could you confirm the scope of this policy, in particular whether it applies to patients requesting a shared care arrangement with private clinics only, or to patients of NHS services as well? Were GPs specifically instructed not to engage in shared care arrangements, or only told that they may not be reimbursed when doing so? Does this apply to Plymouth only, or across the whole Devon area?
“I believe current patients would also appreciate some reassurance regarding ongoing hormone prescriptions. Will shared care agreements already in place be honoured, and prescriptions for those patients continue to be written and fulfilled?
“We note that the Devon Formulary and Referral website still has the following guidance, which differs substantially from the new position: https://southwest.devonformularyguidance.nhs.uk/formulary/chapters/6.-endocrine/gender-dysphoria-and-transgender-prescribing
“In particular, it states: “Regulatory guidance and NHS England’s current commissioning protocol supports a decision by a GP to accept a request made by a private on-line medical service to assume responsibility for prescribing, and for monitoring and testing[…]”
“Furthermore, I have the following follow-up questions:
1. Please could you disclose when this decision was made, and by which body within the ICS or CCG?
2. Given that gender dysphoria services are commissioned nationally, please explain how Devon ICS had the remit to take this decision?
3. Are there plans to update the Devon Formulary and Referral website to reflect this change in policy towards shared care arrangements for gender dysphoria?
4. Please could you explain how this is compatible with the national guidance for GPs regarding shared care arrangements for the treatment of gender dysphoria. See “Primary Care Responsibilities in regard to requests by Private On-line Medical Service Providers to Prescribe Hormone Treatments”, 2018, LINK – https://www.dpt.nhs.uk/resources/leaflets/gender-identity-information/primary-care-responsibilities-in-regard-to-requests-by-private-on-line-medical-service-providers-to-prescribe-hormone-treatments
5. Please could you explain how this affects the ability of GPs in Plymouth to offer “bridging prescriptions” to patients who are deemed at-risk due to self-prescribing with hormones from an unregulated source, as described in the guidance above?
“We note with concern that this policy may lead to an increase in people self-prescribing through unregulated channels, causing greater costs to the NHS overall in the long run if things go wrong. As this policy will likely mean many transgender people are unable to access Hormone Replacement Therapy altogether, we expect the withdrawal of care in this instance to lead to a further burden on mental health services due to the mental distress that will result, and an increase in admissions to A&E, for example due to suicide attempts and self harm. The incidence of these among patients with untreated gender dysphoria is well established.
“We appreciate that there may not be time to address all of these issues during the meeting. If not, please could you provide us with a deadline by which we may expect an answer?”
[5] Full statement received from OneDevon Integrated Care Board:
A spokesperson for NHS Devon said:
“Gender dysphoria services are commissioned nationally by NHS England and are delivered through seven specialist regional Gender Identity Clinics.
“For adults in Devon, services are provided by the West of England Specialist Gender Identity Clinic (also known as The Laurels Clinic) in Exeter.
“The Tavistock and Portman NHS Foundation Trust Gender Identity Development Service (also known as the Tavistock Clinic) in north London provides services for children and young people (under-18) across the country.
“We are aware that the Tavistock Clinic is due to close, with new centres to be set up in spring 2023. Until then, however, the service remains open.
“The specialists at the Gender Identity Clinics make recommendations for the prescription and monitoring of therapies and treatments (such as hormone therapy) but do not directly prescribe them.
“Instead, GP practices can choose to enter into a shared care arrangement with a clinic for prescribing and monitoring. It is for the individual GP practice to decide whether to enter into these arrangements and is not a decision that NHS Devon are involved in.
“To support GPs, NHS Devon is operating a funding framework for practices who take on shared care arrangements with NHS and non-NHS providers. Each application is considered on a case-by-case basis and, if approved, NHS Devon would provide funding to support the practice.
“We are producing an update to send to all GP practices across Devon to clarify the above information.”
ENDS
The image for this article is from wikimedia commons and licensed under the Creative Commons Attribution ShareAlike 2.5 License – https://commons.wikimedia.org/wiki/File:Transgender_symbol_pink_and_blue.svg
