During the summer months there has been quite a lot of behind the scenes activity going on regarding the inconsistent levels of NHS provision for people with gender identity issues.
I had already been working for some time this year with the specialist commissioning group in Yorkshire and Humberside region. That work has led to commissioners for that region developing what we believe to be the best policy and service specification to date.
By coordinating consultation with representatives of the Gender Trust, Press for Change and Charing Cross Gender Identity Clinic, and by carefully educating the commissioning team, we've arrived at something that, whilst not perfect, represents a significant advance on any previous policy.
The policy and service specification has now been approved by the full regional Specialist Commissioning Group (SCG) and is expected to be ratified by Yorkshire and Humberside's 14 Primary Care Trusts (PCTs) in October. That will mean that treatment and funding policy in the Yorkshire and Humberside Region will be consistent.
With a best practice approach to refer to, I've also been having a similar kind of discussions with the commissioner responsible for the same policies in the North West – although that work still has some way to go. The goal is to gradually infuse better practice, one region at a time.
Yet this also takes place against a setting where we know that many PCTs are still operating policies that amount to a blanket ban on treatments. This is ten years after the Court of Appeal upheld an earlier high court decision (A.D.&G vs NW Lancs Health Authority) which said such behaviour was unlawful.
The PCTs that do this are never so obvious as to say that they are banning treatment of course. No. What they do is to set policies which say they'll not routinely fund treatments, but that people can apply for special consideration under the Trust's "Exceptional Cases" procedure.
Such PCTs can seldom define what would constitute an exceptional requirement though, and in practice some have never made such an exception. When challenged on this by patients prepared to take legal action, they will deny the intent behind their behaviour all the way to the steps of the court and then miraculously make an exception.
There are several well-documented cases around the country where this kind of thing has been happening and, if anything, it seems to have got worse in some areas over the last year or two. For instance, Nottingham Teaching PCT had a policy of this kind, which I criticised to their faces in a conference in the City last year organised by the Department of Health's Equality and Human Rights Group.
Other parts of the East Midlands region had policies which funded assessment and treatment of gender identity issues to varying degrees. However recent changes, meant to centralise policy making on so-called "Specialist Services" at regional level, led to a consolidation exercise in each of the ten English Strategic Health Authority regions.
And in East Midlands, rather than levelling services up to the best, they decided they would level down "to be fair". The plan was to adopt the restrictive Nottingham policy for the whole of the rest of the region.
The situation became so bad that one Nottingham patient embarked on a hunger strike, vowing that she was prepared to die to draw attention to what was going on. Fortunately, after a week, she called off the action, telling the BBC "I've been assured that they will fund and support me". Health services should not have to work in this way for anyone.
Departmental Blind Spot
I've been associated with the Department of Health's Equality and Human Rights team for several years now (since 2006), and I and my colleagues have never missed any opportunity to draw attention to these problems and urge the Department to deal with them.
In September 2008 I was formally appointed as an Advisor on LGBT health issues and felt, by then, that there was sufficient documented evidence (in press reports alone) to move beyond the need to measure and prove the problem. Instead, I advised the Department's equality team to address clear and unambiguous challenges:
- To address the issue of poor commissioning policies in England and promote a best practice approach with adequate funding and choice to address all the documented issues of delays and obstructions
- To address the issues of General Practitioner knowledge and behaviours (as highlighted by the "Engendered Penalties" report in 2007)
During the past year I've then pursued these two targets at every available opportunity, being careful to ensure that additional objectives were not allowed to creep in and dilute attention. (Given the opportunity, officials will always put their efforts into the easiest task and use that the deflect attention from harder topics).
However, as the first year of the Department of Health's LGBT Advisory Group drew towards a close, it was apparent that nothing whatsoever had been achieved on either of these objectives. Worse, we seemed to be going backwards, when Ten Downing Street issued a very poorly informed response to a petition about similar problems in Oxfordshire.
Readers of this Blog will know that I wrote immediately to my associates in the Department of Health pointing out the issues with the Number Ten response and demanding action.
Shortly after these events I had another meeting of the LGBT Advisory Group, in which my patience and diplomacy simply ran out. Politicians would say that a "full and frank exchange of views" took place.
Following this I also briefed contacts in the Equality and Human Rights Commission (EHRC), who are already undertaking a very detailed investigation of other issues, continuing work begun by the former Commission for Racial Equality.
The issue is that whilst PCTs are autonomous and the Department cannot order them how to apportion their budgets, Ministers do have an absolute responsibility to ensure NHS Trusts don't break the law or violate the principles of the NHS. By now, the officials at DH were conceding that they knew this was what was happening in the case of gender identity patients in some parts of the country.
The issue is made worse by the fact that I had also put forward a suggestion that the Department could address the policy issue very easily by offering to publish the "Guidelines for Commissioners" produced by the Parliamentary Forum on Gender Identity.
This was meant to hand the officials a solution on a plate ... a lifeline which the Equality and Human Rights team at DH seemed quite enthusiastic to seize. However, in our frank exchange of views (above) it had emerged that the Mental Health team in DH, who have policy responsibility for Gender Identity services, was only prepared to "welcome" the guidelines. They were categorically opposed to publishing this clear guidance under an NHS or Department of Health logo.
At the same time as briefing EHRC I also agreed the text of a Parliamentary Written Question with Lynne Jones MP, which she agreed to submit. As Parliament was in recess for the summer, this has only just been answered. However, it has also now been the prompt for the Department to assure me in person that a letter will be going to the Chief Executives of all English PCTs later this week, on this very issue.
When the letter has been sent and I have a copy I will Blog it here. I'll also cover the formal response to the issues I've raised personally with the Department. In the meantime, however, here is the Parliamentary Question and its' answer.
Note that these kinds of answers are usually couched in very careful words like this one, so the value isn't in the words but the fact that the issue has been forced up to the most senior levels, involving Ministers and the Chief Executive of the NHS, David Nicholson.
16 Sep 2009 : Column 2238W—continued
Gender Identity Disorder
Lynne Jones: To ask the Secretary of State for Health what steps he is taking to ensure that all primary care trusts provide accessible, timely and high quality gender identity services. 
Mr. Mike O'Brien: The Department is committed to the delivery of high quality national health service gender identity services. Primary care trust commissioning of gender identity services remains a matter for local prioritisation, with access to services determined by clinical need and local decision-making.
The Department is in the process of writing out to all NHS chief executives and their teams, via the weekly NHS leadership team bulletin the week, to reiterate this commitment to high quality gender identity services and the importance of considering such cases individually, according to clinical need.