Saturday, February 05, 2011

The Impact of Health Cuts on Gender Reassignment referrals

I've been hearing several verified accounts from around the country where Primary Care Trusts have been issuing policy letters to Gender Identity Clinics, restricting referrals for patients with Gender Identity Issues.

So far as I can see, the PCTs concerned aren't singling out gender identity referrals alone. Generally there are whole categories of treatments which have been lumped into the same boat.

One glance at those lists will reveal, however, that the other treatments subject to cutbacks are generally those which would be considered as 'elective' and generally low priority.

This tendency to lump gender identity patients in with people seeking (say) tattoo removal suggests a certain mindset on the part of the managers concerned.


This is a topic I've sought to act on before. In September 2009 I was successful in getting the Chief Executive of the NHS, Sir David Nicholson, to issue explicit guidance on the topic -- as reported on this blog.

I've also written more generally about the discipline which PCT commissioning managers must follow when changing any policies like this. Again, you can read that here on the blog and here for a more specifically NHS audience.

What the Government says

Baroness Gould, a Labour Peer who is taking over from Dr Lynne Jones as chair of the Parliamentary Forum on Gender Identity has sought to obtain some reassurances from the Government on this matter. Her written Parliamentary Question and the corresponding answer by Earl Howe, Parliamentary Secretary of State for Health, can be seen below.

As you'll see, the Government says more or less what I've explained in more detail here. Consequently the first avenue for challenging any policy change by PCTs affecting access to gender identity treatments should be to demand to see the Equality Impact Assessment (and to check that it was carried out before the policy change was introduced).

Do PCTs still have to do equality impact assessments?

Note that, after the new Public Sector Equality Duty comes into effect in April you may encounter managers who try to argue that they no longer have to carry out Equality Impact Assessments. This is misleading.

It is true that the new legislation changes the emphasis and terminology from "assessing" to "analysing" and that organisations will no longer have to publish all the paperwork; however they are still required to be able to justify a decision on the basis of having analysed its' effects and ensured that they are complying with the general duty to :

  1. Eliminate unlawful discrimination, harassment and victimisation and other conduct prohibited by the Act; and
  2. Advance equality of opportunity between people who share a protected characteristic and those who do not; and
  3. Foster good relations between people who share a protected characteristic and those who do not.

This is what the Equality and Human Rights Commission say in their non-statutory guidance on the new duty:

"Under previous duties you were required to set out how you would assess the impact of policies and practices on race, disability and gender equality, including gender reassignment. The requirement to set out how you will assess no longer applies, but under the new equality duty you are required to analyse the effect of your policies and practices and how they further the equality aims, and to publish the results of that analysis and the information you used."

So, the position is clear enough. Make sure you demand to see that the PCT has thought about what it is doing.

Parliamentary Question and Answer

Question Number: 5883

Date of Answer: 24.01.2011
Column References: 724 c109WA

Member Tabling Question: Gould of Potternewton, Baroness  Topic: Health: Spending Cuts

Question: To ask Her Majesty’s Government what guidance is being given to primary care trusts to ensure that the cuts to services are not being targeted in a discriminatory manner; and what steps they are taking to ensure that the cuts do not discriminate against gender re-assignment cases; and whether they will ensure that their financial policies are equitable and have been subject to equality impact assessments.

Member Answering Question: Howe, Earl

Answer: Primary care trusts, as with other National Health Service organisations and public bodies, must fulfil their statutory responsibilities under the Equality Act 2010, including assessing the impact of their decisions. Guidance is available from a number of sources including the Equality and Human Rights Commission and NHS employers with whom the department is working to support the NHS to implement the Equality Act. The NHS chief executive wrote to all NHS organisations in September 2010 reminding them that compliance with both the spirit and letter of the Act is essential during transition. The NHS Operating Framework 2011-12 also reminds NHS organisations to ensure that all decisions are taken with due regard to the public sector equality duty to ensure that decisions are fair, transparent, accountable, evidence-based and consider the needs and rights of staff and patients across all the equality characteristics.


siobhan said...

hi christine, could you share the names of the PCT's which are starting to restrict GIR? It is importnat that this does not go unchallenged, and it shouldn't have to be trans people waiting for ops who have to do the challenging. thanks for this article, xxx siobhan

Christine Burns MBE said...

Dear @siobhan, I will be sharing the information I have in a forthcoming meeting with policy officers of the EHRC, who are examining adverse outcomes for trans people.

For this reason I would be very grateful if people would use these comments to cite examples I can add to that list

Jen said...

I'm in Ashton, Wigan and Leigh PCT. I must say that I'm quite pessimistic about my future in the current climate. I guess I'll find out soon after my first appointment at Charing Cross in April.

Christine Burns MBE said...

@Jennifer, if you've got a first appointment then that means that your PCT has agreed to fund the referral.

The situation of concern is where PCTs (or regional level Specialist Commissioning Groups - SCGs) have written to a clinic like Charing Cross to say, "don't accept referrals from our area for a period of time". The only thing such clinics can then do is to decline any requests they get from that area.

Another scenario that's emerged is where the clinic then wants to go on to refer a patient to one of the hospital trusts who carry out gender reassignment surgeries.

These referrals need the consent of the PCT, as the hospital is a separate provider. In many cases that's just a formality. At least two regions commit that if they are referring someone to a gender clinic then they're committed to funding the treatment to its' clinically appropriate end point. However, that's not the case in EVERY region. What I'm seeing is some commissioners employing what can best be described as stalling tactics - creating extra paperwork hoops for the gender clinic to jump through to 'prove' that the onward referral meets the letter of the conditions which these kinds of commissioning policies sometimes contain.

Jen said...

Thank you Christine. That's a relief.
My concern, perhaps naively was the willingness of my PCT to fund my treatment post referral, like them saying the pot is empty, you are a lower priority. I simply have no idea of how things work. But for me at least, what you say is heartening. For people behind me this must be very worrying.

siobhan said...

thanks christine. good luck jennifer. I'm working with a queers against cuts group in the north west, let us know if referrals start being stopped in your area.

xx siobhan

Natasha said...

Stoke-on-trent pct have stopped all funding for gender reassignment as well : (

Guess it's internet hormones for me. Hope other people have better luck than me.

Anonymous said...

anyone denied sexchnage surgery and therapies can easily challenge their PCTs in the ECHR by simply quoting the ECHR verdicts in the cases of Schlumpf v Switzeland and Van Kuck v Germany and also Goodwin v UK in which cases the court said that anyone who changes to live in opposite sex is clearly transsexual and to deny the surgery is a beach of Articles 8 and 12 and also extends to Article 3 and 14.