Saturday, March 30, 2013

New Disability History Timeline

Disability Timeline Front Cover

A new timeline of disability through the ages documents that, in ancient Aztec society, the royal zoo included a display of disabled people who lived on scraps of food tossed into the cages.

And the idea of 'deserving and undeserving poor' is not new - in the 1300s English law allowed discrimination between the ‘deserving’ and ‘undeserving’ poor claiming alms, with specific reference made to disabled people.

Legacy publication

The new Timeline, published by NHS North West's Equalities Team in their last week of operation, aims to document how attitudes towards disability have differed (or not) through the ages and across cultures.

It also marks the contribution of individuals and groups to advancements in health and social care in relation to disability; and it highlights legal and other landmarks in the struggles towards equal rights of disabled people.

You can download a PDF of the timeline booklet here.

A plain text version is also available here for people using text reading software.

Third in the series

This is the third such resource which NHS North West’s Equality, Inclusion and Human Rights team has produced.

In 2008, to mark the 60th anniversary of the NHS, a BME History Timeline was produced to honour the contribution of Black and minority ethnic staff to the health service since its inception.

In 2011, a similar LGBT History Timeline acknowledged how lesbian, gay, bisexual and transgender people contributed to, and challenged, medicine and health care through the ages. I wrote about the online spinoff here.

Shahnaz Ali, Director of Equality, Inclusion and Human Rights at NHS North West, said:

'On the eve of our dissolution as a strategic health authority, we are proud to launch this latest History Timeline which we hope will be a long-lasting and valuable educational tool for the NHS and other public sector bodies.'

The booklet which accompanies the Timeline was published just before the team was disbanded and includes information on:

  • Stereotypes, cultural representations and attitudes
  • Legislation and policy
  • Achievements of the disability rights movement
  • Social advances
  • Achievements in the North West
  • Medical and technical developments
  • Key individuals

Integrated resource

The three timelines have been designed with a similar format.

Each consists of a large public exhibition, made up of around 20 large mounted display boards suitable for erecting in reception areas, in corridors, or at conference events. Stakeholders were involved closely in the research and design in each case.


Each exhibition has been complemented by a short film, made into a DVD and also available online. The films feature both BME / LGBT / Disabled NHS staff and stakeholders, discussing why an understanding of their needs as staff or patients is important.

Finally, each exhibition has also been complemented by a printed booklet (available online in PDF format).

The booklets serve several purposes.

  • Firstly, they contain a lot more material which there simply wasn't room for on the exhibition boards
  • Secondly, they provide something which exhibition visitors can take away to study in more detail.
  • And, lastly, they provide a way of extending the usefulness of the resource online, in conjunction with YouTube versions of the videos.

Booking access

The two existing timeline exhibitions have been in continuous demand since they were first launched. They've not only been used on NHS premises in the North West but have been requested around the country, and used by other public sector organisations such as the Police and Prison Service, by Voluntary Sector Bodies, and Unions.

To extend access to the resources, we previously made online versions available. Unfortunately it wasn't possible to do this for the Disability Timeline in the time available; however this is something that maybe the new NHS organisations will take up.

Bookings for the exhibitions have been managed until now by the NHS North West Equality, Inclusion and Human Rights team. With the disbanding of the team, we have managed to make arrangements for the Greater Manchester Commissioning Support Unit (GMCSU) to assume responsibility.

The GMCSU has also agreed to stage a public launch of the completed Disability History Timeline in Salford on Wednesday 8th May.

Your contact for both bookings and the launch will be the GMCSU's Equality and Diversity Manager, Julia Allen ( In addition to email you can also reach her on either 0161 304 5333 or 07824 599398.

Coming soon - New training resource for clinicians and commissioners on men's health

The introduction to the new video, which will be launched next month

Legacy resource
One project we didn't have time to complete and launch before the closure of NHS North West and our equalities team was a new resource aimed at helping commissioners and primary care clinicians to tackle the health inequalities experienced by men and boys as a group.
We will be finishing and launching it next month though, in our own time.
The idea for this development began when we had talks with one of our strategic stakeholder partner organisations, the Men's Health Forum (MHF) last year.
The MHF were looking for some investment to support running a couple of events to educate NHS commissioners and primary care staff about one of society's greatest areas of health inequality … the shorter life expectancy and poorer health outcomes for men and boys.
This idea of stakeholder groups coming to us with evidence-backed proposals for strategic interventions was something we encouraged. Rather than people just coming to us with problems, we always preferred them putting forward practical solutions which we could work on together.

When I looked at the initial request from the MHF, it was obvious that the education they proposed to provide to managers and clinicians would be valuable. I've seen their presentations before, and I know their evidence and best practice ideas are sound. However, I thought we could better what they were asking to do.

It was all very well supporting one or two events, but how far would the effects of those reach? This is a national challenge. A little intervention in just one part of the country would not make much of a dent in the problem.

I thought that if we were investing money in this area we should do it much more strategically, and produce a resource that could be used over and over within the NHS for a long time to come.

Thus the plan for this video package was born, along with the plans for how it will be used.

It's another one of our legacy projects.

Taking it forward

The Men's Health Forum will be responsible for taking it forward. We've simply invested in them having the tools to do the job.

They will be running educational events nationwide using the video as part of the overall package.

They will also be teaching GPs and CCG leaders about established best practice ideas for reaching out to men and boys.

But the video material could also be used on its own too, to encourage GPs (in particular) to think differently about how to reach men and boys.

Not rocket science

Part of all this is about understanding the various ways in which the health and wellbeing prospects of men and boys could be improved, just through a combination of more effective screening and getting men to change their (and their sons') behaviours.

Part of it is about communicating techniques that work, to get men and boys engaged in helping themselves. Some NHS managers will tell you (without a trace of irony) that men are 'hard to reach'. This is clearly absurd. The trick is to understand the different approaches needed to engage more successfully.

None of this is actually rocket science.

The health research has existed for years. And the engagement techniques have been shown to work where they've been tried. Some of the Primary Care Trusts in the North West had already set up some very promising schemes which I hope will continue beyond the reorganisation.

However, it is too easy for both clinicians and policymakers to fall into the lazy assumption that these kinds of health inequalities are set in stone as 'natural differences' between men and women.

The neglect then contributes to massive differences in health outcomes between men and women in comparable circumstances, and between groups of men in different parts of the country.


The final editing of the film was finished earlier this week and DVD copies of the video are now in production. We'll also arrange for it to be available online and I will host an audio version on the Podcast which complements this blog.

It includes some great contributions by MHF and European Men's Health Forum President, Professor Ian Banks; MHF Trustee and epidemiologist Professor Alan White; and former MHF Chief Executive, Peter Baker, who now works as an independent consultant in this field.

The Men's Health Forum are developing the training and associated marketing around a new initiative, which our video helps make possible.

MHF will also now be responsible for launching all of this, on 30th April, in Manchester. For details contact the Men's Health Forum.

Research derailed by obstruction in GP practices

Trans Research Cover

With the NHS North West Equality, Inclusion and Human Rights Team shutting down this week, there's been a flurry of activity to complete all the remaining projects and publish them.

One of those publications was a report on research which the team had commissioned to help NHS commissioners identify how to improve the quality of care and services as experienced by people who are seeking to undergo, are undergoing or have undergone a gender transition.

One of the researchers on this project, Jay McNeil, presented a summary of the project's findings earlier this month, at an event which I attended.

My report on that event is here.

And the new report on this research can be downloaded here from NHS North West or here on the authors' site.

Modest aims

The aims of the research, confined in scope to England's North West, were fairly modest … this being a pilot study to provide pointers for more work to follow. The objectives were:

  • To generate an evidence base for trans health; and
  • To improve GP access for trans people

Meeting these aims, it was hoped, would inform commissioning, add valuable data to direct health care provision, and be a step on the path to enhance the health and well being of trans people.

The first strand of the project, to generate an evidence base, involved obtaining anonymous data from a sample of GP practices in the region concerning the number of trans patients that they had, any comorbidities those patients were being treated for, and the distances that people had to travel to access gender services.

The second strand involved sending trans positive posters to practices, which could be displayed in waiting rooms. It was intended that these would send a clear message to trans people accessing the service that they would be safe and valued, to encourage them to attend GP appointments and discuss their healthcare needs.

Trans GP Poster

Much needed

The project was conceived early in 2012, following on from our success in launching 'Pride in Practice' … a toolkit approach to help GP practices care better for Lesbian, Gay and Bisexual patients.

We were able to support the development of Pride in Practice because earlier work carried out by the Lesbian and Gay Foundation and other stakeholder organisations had already laid good ground, demonstrating that a reasonable number of GP practices would welcome and embrace this kind of approach. It was also immensely helpful that other organisations had been doing work further upstream with NHS commissioners and provider organisations, in the form of the Navajo Chartermark Awards.

Practices don't all embrace 'Pride in Practice'. Pathfinder work, providing LGB service signposting literature to display in practices across the region, met with mixed reactions. Some practices refused point blank to display such information. In some other surgeries the posters were torn down after being pinned up.

However, that pathfinding work also identified an encouraging number of practices who would be receptive to help that would improve their knowledge and services. It made sense to support the enthusiastic practices that way, therefore. Bringing other less-willing practices on-board would have to be more of a long term project.

When designing the 'Pride in Practice' approach, however, we knew that it would be too ambitious to include trans issues into the initial package.

Understanding of trans patients' experiences and requirements was some way behind, compared with the growing social understanding of LGB needs.  And there was already plenty of anecdotal evidence about GP resistance towards trans patients.

Our promise, therefore, was that we would mount a separate project to gather evidence to inform a longer process of catch-up for trans patients.

A successful failure

The US space agency NASA described the outcome of the famous Apollo 13 mission as a 'successful failure'. Whilst the craft was crippled and the mission aborted en route to the moon, mission controllers achieved the seemingly impossible. Despite everything they returned all three astronauts safely to earth. Much was learned in the process.

Something similar might be said of this research project.

The astonishing levels of obstruction (and downright lies) by some practice management and reception staff meant the initial objectives were largely unmet. However, the evidence of that obstructiveness, coupled with other evidence of serious and damaging attitudes in General Practice towards trans people, provides all the data required for the new management of the NHS to get on and address a serious culture problem.

We wish them well with that.

Leaving with Pride

Leaving 3PP 1 Cropped 2

On Thursday this week (28th March) my colleagues and I shut down our operations at NHS North West and left the building for the last time, arm in arm and with proud smiles on our faces.

NHS North West and the other nine Strategic Health Authorities (SHAs) lose their statutory authority tomorrow, along with 151 Primary Care Trusts. These all therefore close.

In their place, NHS England (formerly known as the NHS Commissioning Board) and a system of 212 Clinical Commissioning Groups will take over the reins, largely determining how services are designed and purchased to meet the clinical needs of communities across England (Wales, Scotland and Northern Ireland have entirely different systems).

Musical chairs

Many of our colleagues will have jobs in the new structure.

NHS England itself will be employing about 5,000 people … which makes it roughly the same size (in headcount) as the ten Strategic Health Authorities which are disbanding this weekend.

The 212 new Clinical Commissioning Groups (and bodies called 'Commissioning Support Units') will absorb many of those who previously worked in England's 151 primary Care Trusts.

Finance specialists will continue to be indispensable, handling an even more complex market-based system.

Contracting specialists and lawyers will carry out even more complex roles than before, as the ramifications of a competitive market begin to affect everything the system purchases.

Commissioning specialists will continue carrying out the detailed process of determining needs, obtaining evidence, taking account of best practice, designing, procuring and then managing services which doctors refer us to when we need them. They'll just have new masters setting policy.

Those who plan and commission the training and continuing education of doctors and nurses will still be needed to do this, although they'll be working in different structures for a new body called Health Education England.

Specialists in public health will be hit to a degree, as the responsibility for this policy area shifts to local authorities, under a new body called 'Public Health England'. I say they'll be affected 'to a degree' because the restructuring will mean there are fewer places for very senior Directors of Public Health.

But, overall (when the music stops), I believe that more than 85% of NHS staff will continue to have similar roles in the new structure, created at an estimated cost of £3Bn.

And what of equality?

One function which doesn't survive the reorganisation very well is Equality, Inclusion and Human Rights.

I've written in previous blogs about how that has come about. And I will write in future blogs about the structure of NHS England's new Equality and Health Inequalities team, once I've finished determining who's who.

Equalities leads in the NHS organisations which provide hospital, mental health and ambulance services (so-called 'Provider' organisations) will continue more or less as before … at least for now. Provider organisations are not affected by this weekend's reorganisation, though they are predicted to suffer mergers and closures in the months ahead as that side of the system comes under fire from several directions at once.

Some PCT equality leads have found places in new Commissioning Support Units, where they will continue to have some equality and inclusion responsibilities … though early signs are that they will have quite narrow functions. Far fewer have found roles in Clinical Commissioning Groups (who've largely decided they don't need such skills on board).

Some PCT and SHA equality leads with mouths to feed have also jumped into the lifeboats offered by completely different job functions, when it became clear there was no other option for them. We are waving goodbye to some great policy leaders who will have their heads down now, doing other things.

A couple of existing SHA equality leads also look as if they've secured posts within NHS England's equality and health inequalities team … though details are sketchy.

The greater majority of equalities knowledge and expertise has either departed already though, or will have gone this week.

For me, as a consultant, it is not a case of losing a job, but losing a client. I'm spared that label 'redundant'.

My colleagues at NHS North West were not just clients though, and I'll be staying in touch and perhaps reporting their next moves at some time in the future.

Thursday, March 21, 2013

New role for former Department of Health "Equality Czar"

HSC BME Network

The following Press Release has been received from the Health and Social Care BME Network. Whilst I rarely reproduce press releases verbatim in this way, I am making an exception in this case because of the relevance of the news to those interested in the changes to NHS equality, diversity and human rights organisation at present. In practice, Surinder (who has been at the Department of Health since October 2004) has taken very much of a back seat in the last 2-3 years. He will be well known to those who were involved in the big development of equality and diversity work at the Department in the first few years of his tenure.

Press Release

Surinder Sharma the man appointed the nation’s first ever Czar - the National Director for Equality and Human Rights at the Department of Health - has taken the helm of the HSC Network’s Governing Council. As Chair he will guide the process of alliance building which is at the heart of the Network’s mission. On taking up the appointment he said:

“I am delighted to take on this role and continue to build on the very necessary work that needs to be done to ensure the healthcare sector embraces diversity and delivers fairness for all. The Governing Council provides an opportunity for professionals at the top of their game to put their heads together and come up with pragmatic solutions to some of the intractable challenges we have faced over the years”.

Dr Isaac John the Chair of the HSC BME Network, who was himself appointed a Trustee of the prestigious Tutu Foundation UK last week, commented:

“Surinder is well respected in the sector and by the communities we serve. He brings a wealth of experience and insight to the Network and has the standing required to engage leading professionals in the challenging business of creating inclusive healthcare organisations. Under his guidance we are certain our efforts will bear great fruit”.

About the Network

The formation of the Network recognises that BME staff across the public sector share similar experiences and it is to our advantage to stand together to protect the gains of past years and continue the struggle for equality of treatment and outcomes.

About Surinder Sharma

Surinder is the former National Director for Equality and Human Rights reporting to the Chief Executive of the National Health Service and Permanent Secretary and the Chief Medical Officer for England at the Department of Health.

In 2005 he became a Consultant to Novartis and founded its Global Diversity and Inclusion Advisory Committee with a membership drawn from China, India, South Africa, USA, UK, Switzerland, Germany, Mexico and Hawaii.

At the Ford Motor Company he managed a budget of £8 million across Europe.He developed Ford’s European Diversity Strategy aligning it to European Business Strategy to ensure Ford’s achievement in becoming an employer, supplier and brand of choice and a good corporate citizen.

At Littlewoods he made the critical shift in the company’s thinking to equal opportunities being not just a moral issue but a business imperative. Surinder worked extensively with the Owners, Managing Directors and Executives of 7 different parts of the business - Index, Littlewoods Stores, Home Shopping Group, Business Express, J&C Moores, Littlewoods Pools and Lotteries - employing in excess of 27,000 people. During his tenure The Littlewoods Organisation was recognised as an example of best practice in the field of Equality and Diversity.

Early in his career he worked for BBC Television where he established, developed and managed the BBC Television Equal Opportunities Department, managing 11 members of staff and a budget in excess of £3 million.He embedded equality into the culture of the organisation with a public service remit towards recruiting the best people, thus enabling the BBC to meet the needs of a diverse license paying audience, by portraying on screen the nation it serves.

At the Commission for Racial Equality Surinder held a variety of posts including Complaints Officer and Senior Field Officer, which set the foundation for the work he currently does Chairing Leicester Race Equality Centre.

Current Honorary Appointments

Surinder has served on many important boards and is Member of Council Aston University, Chair of Ethics Sub Committee. He also serves as:

  • Shadow Governor for Leicestershire Partnership NHS Trust, which is applying for Foundation Status.
  • Vice Chair Healthwatch Transition Board for Leicester.
  • Trustee of UNICEF United Kingdom.
  • Leicestershire County Council Independent Person with oversight of the Member Conduct Complaints Process.
  • Chair, Leicester Race Equality Centre.
  • Trustee of the National Space Centre.
  • Honorary Professor by the University of Manchester Business School.
  • Honorary Doctorate from Birmingham City University & De Montfort University.
  • Honorary Professor from the University of Wolverhampton.

Wednesday, March 20, 2013

Jam without the cream or scone


There's an interesting profile in today's Guardian about Professor Steve Field.

Steve, for those who don't know, is the man effectively in overall charge of both Equalities and Health Inequalities at the new NHS Commissioning Board, within his role as Deputy Medical Director.

His NHSCB appointment was announced last August. Shortly afterwards, he was given the leading brief on health inequalities in the hasty reorganisation necessitated by the resignation of Jim Easton.

The idea was to work alongside a colleague, Paula Vasco-Knight, the Chief Executive of South Devon Healthcare NHS Foundation Trust, who had been asked to spend a day each week championing equality in the new
NHS quango.

However there is no mention of the latter's part in today's profile, and one rather gets the impression from the language that Field may now look upon the whole function as his own.


Steve is a Birmingham GP (he still practices each Friday) and he was the Chair of the Royal College of GPs before the present incumbent, Professor Clare Gerada.

He is also better known as the man who chaired the controversial Future Forum, leading consultations over Andrew Lansley's Health and Social Care Bill when Parliamentary progress was "paused" in 2011.


The Guardian profile portrays Field as a man with a passion. All well and good.

We learn about his upbringing and the origins of his concerns about health inequalities.

We learn about how he keeps himself grounded in the realities of primary care by seeing patients at his Birmingham practice one day a week.

We are also treated to a demonstration of some understanding that health inequalities are not just about place and socio-economic factors, but about who you are as well.

He cites a few well-documented examples of how health outcomes for sex workers, gay men, lesbians, gypsies and travellers, and older people are heavily influenced by the circumstances of those groups and the discrimination they experience.

That hat tip towards bringing diversity into the narrative about health inequalities is welcome, if horribly overdue at such a senior level.

Stakeholder groups have been telling everyone who'll listen about those kinds of inequalities for years. Here's an even longer list.

So, if Field is intending to build and develop that part of his narrative about health inequalities it will be a good thing.

Not rocket science

I'm more disappointed to read that he thinks the widening gap in overall health inequalities is "inexplicable".

Quite apart from the fact that neither Public Health Directors nor PCT Commissioners had paid much interest to the health needs of diverse groups all these years … and that Joint Strategic Needs Assessments have seldom (if ever) charted demographics beyond age, gender and race … the pointers are plain enough.

Texts like Wilkinson and Pickett's "The Spirit Level", spell out the many connections between the size of the inequalities in societies like ours and negative outcomes such as ill health and reduced life expectancy.

The wider the gap between the have's and have nots in our society, and the less control people feel over their circumstances, the more pronounced all the negative indicators (like health inequalities) become.

The Spirit Level was published just over three years ago. Hopefully Steve will make time to read it at some point.

Addressing Britain's socio-economic equality divide is not in his gift of course. But it would help ensure his narrative doesn't slip into simply blaming individual behaviours.

No budget

Field admits to having no budget and to having to rely on persuasion … in which case he'll need to be well on top of the evidence. He can get that from expert stakeholder organisations in the way we showed to work really well over the last few years. The investment in treating expert stakeholders like expert consultants really pays dividends.

But if he is relying on local authorities knowing how to chart their local populations he could be in for a shock.

A 2008 research project by the North West Public Health Observatory and Liverpool John Moore's University, examining the quality of Joint Strategic Needs Assessments in the region, found that whilst there were good examples of agencies working together to collate data and evidence about their local communities, there was also a lot of variation in the quality of data, and commissioners just weren't using the documents in their planning decisions.

The North West sample is not atypical.

In particular, most JSNAs stop at the easy kind of analysis … charting age and sex, and using geography as a proxy indicator for ethnicity and social deprivation.

Disabled and LGBT people don't live conveniently in specific council wards though. They are typically spread across whole areas. Techniques to analyse them and their needs, and then target health improvement and prevention in their direction, requires other approaches.

Some really good innovations have been demonstrated in this regard, but a massive departure of personnel who worked on these kinds of initiatives risks a loss of that corporate memory.


Field and his team of twelve face a big challenge to change thinking about health inequalities and achieve actual outcomes.

It's a long game, with many external factors working against simple attempts to alter behaviours among planners, commissioners and primary care staff.

Some of the real outcomes would take generations to measure.

With no budget, an uphill educational battle (just for local officials) and results that are hard to show in the short term, it's easy to see how the whole team's efforts could be sucked into this effort alone … especially when that is a leader's prime vision.

And my fear is that, because this is Steve Field's passion, the equalities side of his team's brief will suffer.

In turn, that will undermine a great deal more.


Just as health inequalities is a multi-faceted area, so is equality too. And the experience of all these years is that it doesn't look after itself.

Where colleagues and I have dealt with equalities strategy in the NHS, health inequalities have always been a part of the picture. Addressing those inequalities is part of the outcomes you seek.

But it's possible, as I've hinted, to talk about health inequalities (if that's your starting point) and overlook all the other kinds of equality.

Employment inequalities

The NHS is the second largest single employer in the world. (The Chinese Army is the largest and Indian Railways used to hold the number two distinction).

The NHS employs 1.4 million people … mostly at the pointed end in organisations providing healthcare.

Historically, the NHS has had a very strong ethnic makeup. That's because of the repeated recruitment that was necessary in Commonwealth countries after 1948 just to set up a professional workforce.

Evidence abounds that the NHS is not very good at workforce equalities. This was most recently demonstrated in the NHS Commissioning Board's own recruitment data.

It's a subject which senior clinicians have raised repeatedly too. And evidence of discrimination and bullying lay behind our initiative to help ensure that the Medical Revalidation process is not misused.

It is notable that in talking about his passions and vision, Steve Field makes no mention of workforce diversity. And, since he makes clear that the direction of work is principally his decision, guided by his passion for addressing health inequalities, observers are bound to ask what becomes of this other major issue.

Barriers and worse

The other area that has long concerned equalities leaders has been the kind of experience which patients, relatives and other stakeholders have when they are users of and visitors to NHS services.

Only recently I was writing about the GMC's concerns about some GPs actively discriminating against transgender patients.

Last year my colleagues and I launched "Pride in Practice", addressing evidence of similar barriers for LGB patients.

Field pays passing mention to patients being discharged and not being treated with respect. He could be talking about the experience of many groups, but his comments underline the awareness.

We've also looked at how women from different ethnic backgrounds access and experience vital screening services. And we encouraged best practice, such as one scheme by a hospital trust which ensures disabled women are able to access screening too.

Each of these strategic approaches required evidence, followed by consultation to plan them and a budget to support them. They can only get addressed if there is a strong vision seeing the need for them. They are often the sort of things that work better as national initiatives too. That's what makes the work strategic.

When not addressed, many of these factors lead to health inequalities. However, I can easily see how a team sucked into the leader's passion about one kind of work … the health inequalities of a public health kind … can let these other areas slip.

Jam without the cream … or the scone

This is why I fear for the possibility that, with one strong-willed leader focussing on the thing he knows best, one or more of the other aspects of equality will get overlooked and abandoned.

You could argue that in some parts of the NHS there's been more attention in the past on equalities rather than health inequalities. Till now they've operated in completely separate spheres very often.

That's not good where it's happened.

But it's equally bad to let the pendulum swing entirely the other way. To focus passionately on health inequalities and let workforce equality outcomes or patient experience outcomes for protected groups become the poor relations.

That would be like having the jam without either the cream … or the scone.

We'll need to see how it plays out. However, the singular focus on one topic displayed in today's Guardian interview sends a worrying message.

Tuesday, March 19, 2013

Mystery surrounds appointment of NHS Clinical Reference Group chair


Mystery surrounds the appointment of a virtually unknown gender clinic specialist to chair a crucial new advisory group in the NHS.

The decision, recently made public on the NHS CB's web site, appears to pass over senior clinicians whose expertise and track record are far better known to patient stakeholders.

I'm keen to hear from anyone who can shed light on this, as the appointment seems strange in the circumstances.

Clinical Reference Groups

The NHS Commissioning Board has been recruiting volunteers to sit on and chair new bodies called Clinical Reference Groups over the last few months.

These new groups are integral to the design and planning of specialised services, which include all NHS-funded Gender Identity treatments.

I explained how specialised commissioning will work in the new NHS structure in a previous article.

The process to populate these groups has been advertised openly, and would have been seen by the clinical leads and staff of all the existing gender clinics in the UK.

Breadth and depth of experience

Several names would come to mind as clinicians with the breadth and depth of experience to either chair or populate such a committee, which will influence the future evolution of how services are commissioned and the protocols by which they work.

Experience of patient diversity is essential, so one school of thought is that you might pick a chair from one of the larger established gender clinics, seeing hundreds of patients a year drawn from a wide national catchment.

There is one particularly obvious candidate from that point of view.

Experience of policy development is essential too, so another school of thought is that you might pick a clinician with a record of leading on the development of best practice guidelines.

For instance, Dr Walter Bouman (Nottingham) and Professor Kevan Wylie (Sheffield) are both clinical leads of substantial established Gender Identity Clinics in England. Both attended a recent conference with me in San Francisco, developing a global consensus among specialist clinicians for revising medical classification. The latter has also chaired an inter-collegiate committee developing UK treatment guidelines.

You would think that clinicians from these three centres would be the leading contenders to go on and chair any committee advising the NHS Commissioning Board.

Strange choice

The NHS Commissioning Board has now announced the appointments of many of the first CRG chairs, however.

And the selection of a chair to lead on gender identity services is a bit of an outlier.


Now, this is a field that I have been working in for over 20 years. I sat on the Parliamentary Forum on Transsexualism for 13 years. I chaired the first working group set up by the Department of Health to develop educational resources. I wrote the Department's official policy guide. I am the UK's external advisor to the World Professional Association for Transgender Health. And I've sat on more committees and spoken at more policy events than I can honestly remember.

And in all that experience I have never encountered the name, let alone the presence, of John Dean.

Some background

Some digging reveals that Dr John Dean is the lead clinician for a service called The Laurels in Exeter. The clinic doesn't appear to have a web site of its own; however this site by Gay Youth UK provides some details.

Some more digging reveals a biography here, which explains that he is "Clinical Director for Gender and Sexual Medicine for Devon Partnership NHS Trust".

That would be handy, of course, as the Chief Executive for the neighbouring South Devon Healthcare NHS Foundation Trust  is none other than Paula Vasco-Knight, the National Lead for Equality at the NHS Commissioning Board.

Since many equality concerns have been raised around the design, conduct and access to gender identity services over the years, the Commissioning Board's head Champion for Equality is almost certainly likely to know the new Chair of the Clinical Reference Group already.

New broom vs competency

There is an argument, of course, that the governance of policy development in this area might need a clean pair of hands, untainted by all the previous history and enmities.

Gender clinicians in the UK really aren't a model of happy families. In particular, politically, they seem to have divided into "Charing Cross and the rest".

The unifying factor for "the rest" is that, even when their case loads are all added together, they are still only a fraction of the size of the Charing Cross behemoth. You can readily appreciate where they might find common purpose.

However, I look at this from the perspective of a lay expert who has watched the painful evolution of policy for many years. I am a critical friend. I have not been sparing in criticism of what was bad. Equally, I've been generous in helping anyone and everyone who wants to do it better.

For that reason, I would feel rather more reassured if one of the existing experienced players were chairing this Clinical Reference Group and the rest were around the table.

Surely depth and breadth of clinical expertise matters? I would be particularly worried if it turns out that any of those experts are excluded (though the panel memberships haven't been published yet).

To me, regardless of how wonderful he might be in his own small clinical fiefdom, the newly appointed Chair of the Clinical Reference Group for gender identity, is a virtual unknown. And that is a matter of concern. It's akin to putting the head of a tiny cottage hospital in Devon at the head of the cardiology CRG.

Case open

This is why I'm concerned to understand more about this appointment … the logic for how Dean was chosen … where he claims expertise, given his noted absence from anything I've been involved with all these years … and who he is including (and excluding) from the group he will lead.

In my previous blog about gender identity service commissioning I was cautiously optimistic that the new system could actually improve experiences for English trans patients.

That may still be the case. Dr John Dean could turn out to be an inspired choice for chair, sweeping away the past and acting as a new broom. When an unknown gets appointed over the heads of so many more experienced and networked clinicians, however, you are bound to wonder...

The Carbuncle on the face of an old friend


Word on the grapevine has it that I'm not flavour of the month with some big guns over at the NHS Commissioning Board.

Senior figures are said to be "angry" about blogs that I've written recently, expressing my professional views on the new regime's approach regarding equalities and health inequalities.

Word has it they're not happy that I've expressed my professional view that equalities work in the NHS will suffer because of fragmentation beyond even their control.

The jungle telegraph suggests they are even less pleased that I've collated and publicised concerns repeatedly expressed by a list of senior clinicians and academics.

There is annoyance in high places, I gather, because I've highlighted the pensioning-off of a very experienced manager with much still to contribute. Someone was even despatched to rubbish her achievements in anonymous comments below the line. On the internet nobody is as anonymous as they imagine though.

Big cheeses are said to be apoplectic that I've documented the shambles behind setting up the NHS Commissioning Board's own equality team. My forensic reconstruction of events has been described as "bitter".

As I write, they appear to be advertising again for someone to run the team … and now it looks pretty certain which way the job is being tilted.

Spies aren't able to tell me yet what the suits think of me writing about the dramatic loss of leadership diversity in the reorganisation … though I'm writing about something even the Directors expressed concerns about in public session last July. And the analysis is based on their own data.


I don't know why senior figures should be surprised that I write what I think.

As a consultant it's my job to analyse objectively and to have expert opinions. And this blog is part of my work.

The value I've always brought to my clients is that I tell them what they need to know, even if that is uncomfortable. Clients who can't take that are probably not suited to my services. Clients who aren't afraid benefit immensely.

Sometimes what I see looks good and I will report that. Only this week I've written at length about how I believe that the NHS reorganisation may be a positive thing for one protected group of NHS users.

People doing good stuff have nothing to fear.

Sometimes my opinions can be seen by a few as controversial. However, the wonderful thing about blogging is the interactivity. And the comments tell me whether I'm on course with those views or not.

Everyone is welcome to the conversation … even the ones who, for that particular blog, tried to silence me.

Shooting the messenger

That last example was instructive. Yes, there really was an attempt to gag me.

The attempt was based in the misconception that I was an employee of the NHS. (I'm not and never have been).

Sadly I got a first hand view of how the culture of silencing the bringers of bad news works within such an organisation. First priority was to find a policy or contract clause I may have broken. Second priority was an attempt to write a policy after the fact … in the hope of stopping it happening again.

This kind of cultural reaction has been in the news a lot lately. People are horrified that the NHS has used public money and legal chains to silence critics … even to the extent of covering up issues affecting patient safety.

The talk now is all about "transparency" and "values" informing how the NHS conducts itself.

But is it just talk or a real change?

Contagious fear

The message I'm getting from the grapevine is that maybe old habits die hard. There is a very strong impression that parts of the NHS would not now use my services as a consultant because of the "trouble maker" or "maverick" tag.

The latter idea is misplaced, as I've explained. I don't write critically for the sake of it, or to annoy people, or because I'm some sort of loose cannon.

I write objectively about good stuff and bad stuff, as I see it. Think of it as free consultancy. And my interest is about seeing things done better, even if the words are painful for some to hear.

The intelligent way to respond to that is to engage with it. Not by despatching lackeys to troll anonymous comments, but by answering the critique. If I'm wrong then managers should have no difficulty establishing that fact. And I engage with honesty.

That is not the climate that I am still seeing yet though. And it extends not only to the veiled threat of not engaging my services but to staff and stakeholder organisations who might be seen to be "too close".

Independent as they may technically be, equality stakeholder organisations continue to rely on money from the NHS to fund their services. And the impression I'm getting is that the legacy climate of minding your tongue could affect their ability to be sufficiently critical too.

Who pays the piper.

Monstrous carbuncle

The trouble with this kind of thing is that it relies not on what someone actually says, but the impression conveyed.

And if there are managers or stakeholder organisations out there who genuinely feel the need to mind their P's and Q's … who hold back from criticising the NHS because they fear the possible loss of contracts or managerial favour … the NHS is not going to improve the way it must.

This culture thing is (to borrow a memorable phrase from Prince Charles) the Monstrous Carbuncle on the face of an old friend.

Fortunately these days carbuncles can be cured.

I'll know the NHS is getting better when I no longer hear that honest criticism carries risks.

And I'll carry on calling things as I see them … the good and the bad.

Sunday, March 17, 2013

How is trans care affected by the NHS changes?


Over the last few weeks lots of trans people have been asking me one recurring question.

"What is going to happen to the care for trans people under the NHS when everything gets reorganised in April?"

A variation on this question is, "How are people going to be able to influence that care?"

Bad history

It is understandable, given the historical experiences of some people, why fears should be raised.

Until 1999 trans people had no legally assured right to expect care for their gender dysphoria on the NHS.

The case of A.D.&G. vs North West Lancashire Health Authority established through the High Court (and then again at the Court of Appeal) that it was unlawful for NHS organisations to operate policies which amounted (directly or indirectly) to a blanket ban on funding referrals for such treatment.

Even after that case was won, many cases have surfaced over the years where local NHS commissioners have sought ways to ignore the case law and obstruct access to such care.

Different Primary Care Trusts evolved widely differing policies, where they had policies at all.

And they contracted haphazardly for different kinds of treatments to be covered, and often for too few referral places, leading to long waiting lists.

In some instances patients have waited for years just to receive a first appointment. Helping such patients often had to involve legal action. And, faced with the potential costs of such action, patients sometimes decided that they might be better off using that money to pay privately for the care they wanted.

As we are about to see the biggest reorganisation of the NHS's commissioning structure since the 'commissioner-provider' market based system was created, it is inevitable that people should be worried about a whole new set of unknowns.

The old system

In order to understand the changes you need to be aware of how gender identity services have fitted into the NHS until now.

The established 'care pathway' for people expressing distress about their gender has always begun with the patient's General Practitioner (GP).

GPs generally have very little specialist understanding of this kind of need, so the first thing they would do is refer the patient to the local Community Mental Health Team (CMHT).

Gender Identity issues aren't a mental illness; however the role of local mental health professionals has been to ensure the patient is mentally well (some psychiatric illnesses can include trans-like experiences) and to stabilise any conditions such as clinical depression before referring the patient to a specialised Gender Identity Clinic.

There aren't many Gender Identity Clinics in Britain. Certainly, few areas have one on their doorstep. The other reason why local mental health professionals are involved is because it is generally expected that referrals to such 'tertiary' services should be via a consultant-led service like the CMHT.

This stops GPs without the appropriate skills from making inappropriate referrals to out of area services for which there are only limited contractual and budgetary provisions.

Market driven

In the NHS, the provision of care services operates like a market.

On the one hand there are organisations, locally based, which "commission" (i.e. specify, contract and purchase) the services they need on behalf of the community. The organisations that have done that throughout the last decade are called Primary Care Trusts (PCTs). There are 151 PCTs in England (Scotland, Wales and Northern Ireland have different arrangements) and the PCTs are one of the biggest elements of the NHS to change on April 1st.

The other side of the NHS is made up of "providers". These are the organisations which operate general, specialist and training hospitals and mental health services. Gender Identity Clinics are (and will continue to be) part of the Mental Health Trusts dotted around the country.

The 'Charing Cross' gender identity clinic which many people know about is part of the West London Mental Health Trust. It actually has nothing to do with the 'Charing Cross Hospital' virtually next door (and which coincidentally carries out some transgender related surgeries). The colloquial name 'Charing Cross' is simply a historical throwback. The 'Charing Cross Hospital' is actually run by another body called the Imperial College Healthcare NHS Trust. You can see how people get confused!


Usually PCTs would commission local provider services to provide the full range of care requirements for their population. It has always been a principle of the NHS that it cares for all health needs for which there is evidence of an effective treatment.

PCTs, with limited funds every year, set priorities for how many of each kind of service they would budget for. This budgeting process is reflected in the contracts they then make with provider organisations.

If too few places for a service are contracted then either referrals need to stop for the remainder of that financial year (something which has happened in many areas in 2011-12) or they would need to come up with extra money … which can only be done by reducing the spend elsewhere.

This is how waiting lists are often created … and how two adjacent areas can have different waiting times for the same service in the same hospital.

(Note this is a bit of a simplification, as there are different ways of contracting services; the simplification is good enough for this quick explanation though).

Contracting also has an effect on the capacity of services to accept new patients. A gender identity clinic will employ a certain number of staff and choose particular premises based on the number of places which it is contracted to provide. If commissioners get their numbers wrong, or are forced to change their policies by local action, then clinics can't instantly admit more patients just like that. This is the second reason for queues forming.

Specialised services

Gender clinics fall into a category of NHS care called Specialised Services. Basically, these are services for things that are either relatively rare, involve specialist expertise, or might be costly. The list was defined nationally.

For most health needs there are services in each locality. For specialised services it is not uncommon for there to be only a small number of services covering a large area or the whole nation.

Rather than have all 151 PCTs entering separate contract arrangements with each of these specialist services (e.g. for heart transplants or particular kinds of cancer care), the commissioning has been done jointly by so-called Specialist Commissioning Groups (SCGs).

There are ten English administrative regions. Many things are organised at that level. For instance, Strategic Health Authorities have been regionally based, managing the whole NHS in that area. Similarly, therefore, SCGs also brought together all of the PCTs in one region to commission specialised services. I.e. There were ten SCGs.

This is why, until now, the policies for the availability and scope of gender clinic services have tended to be made regionally. (I say 'tended' because there were PCTs who were so determined to restrict or obstruct such referrals that sometimes they opted out of regional consensus).

This regional setting of policies explained the different kinds of treatments which gender clinic patients would be allowed to have. SCGs weren't inclined to collaborate to establish consistent policies or service specifications. The capacity which was contracted for would also lead to different waiting times in different parts of the country.

All these factors combine to explain why gender clinic services were very much a 'post code lottery'.

The new system

All of that detail was necessary in order to dispense with the jargon and make it easier to explain what now changes.

It is easiest to begin with what doesn't change.

The reorganisation taking place on 1st April doesn't directly affect NHS provider organisations (for now) … although they will be indirectly affected further down the track.

Gender Identity Clinics, as they are part of NHS provider organisations, will not be subject to reorganisation.

Existing patients (whose care packages have already been invoiced by the provider trusts) will continue with their treatment … although, where surgical referrals have not already been authorised by the old commissioning bodies, funding for those subsequent needs will fall under the new system.

Gender Identity Services are also still regarded as Specialised Services. The list of specialised services is defined in regulations attached to the Health Act. Therefore, this list isn't going to change too often.

What changes

The most visible changes to the NHS will be the full scale reorganisation of the commissioning and strategic management side of the health system.

On March 31st all 151 PCTs (plus the ten English region Strategic Health Authorities) will all cease to exist. Their place will be taken by a complex system of new organisations, with a whole new set of relationships between them.

The 151 Primary Care Trusts will be replaced by 211 Clinical Commissioning Groups (CCGs). These will be responsible for all the non-specialised commissioning in their own area and their leadership will include local clinicians. In some ways they will look a lot like PCTs; however there are a range of other things which PCTs were responsible for, which will transfer to other organisations.

Overseeing the CCGs there will be an NHS Commissioning Board (NHS CB). Although a national body, the NHS CB will carry out many of its functions through 27 so-called Local Area Teams (LATs). The LATs will supervise CCGs to see that they are operating properly. They will also commission local GP Practices, Dentists, Pharmacy services and some specialised optical services.

The important thing for this discussion is that the NHS CB will also be responsible for commissioning specialised services.

National level consistency

The NHS CB's responsibility for specialised services will bring about the biggest set of changes for people seeking gender treatment.

In place of a multitude of commissioners with different policies, service specifications and contracting arrangements, there will be one standard policy and two set of service specifications for the whole of England. One set for adult services. One set for child and adolescent services.

This will mean that all treatment referrals will be subject to the same policy decisions regardless of where you live in England.

The part of the NHS budget which was being spent previously on these specialised services will be pooled centrally. CCGs won't have control of this part; it will be administered by the NHS CB. New standard contracts will be signed with specialised service providers according to one set of conditions.

What this means is that where £x was being spent on gender clinic referrals each year by the ten SCGs, initially the same £x will be allocated for all needs nationally.

There were many inconsistencies in the ways these (and other) services were commissioned before. Different providers charged different amounts (reflecting the different services they provided) … but also in some cases one clinic might be charging different contract prices to different commissioners. Some commissioners were actually paying through the nose because they hadn't negotiated as well as their neighbours.

Sorting out these inconsistencies will take a while. Therefore the NHS CB has promised providers that, in order to avoid financially destabilising them by sudden changes in their earnings, the services will all receive roughly what they received before, where all other factors are equal (i.e. the same number of referrals and a similar specification of services).

In subsequent years the NHS CB will then 'normalise' what the providers receive, based on a single pricing model (in NHS jargon a "tariff") and the common national service specification. In the process they will probably also insist on changes to cherished ways of working, if these are seen to be inefficient.

Those who are interested in reforming care protocols would do well to learn how to express desired improvements in cost and evidence terms. As the NHS CB will have much more purchasing clout than regional and local commissioners used to have (and as there is no other customer for what they do) the service providers will probably find themselves having hard conversations about aspects of care which can't be justified on evidence grounds.

Levelling down

This is where the picture looks like it may be less good for future gender clinic patients.

In the present system the range of treatments being funded varied between regions (and sometimes between PCTs). The amount of capacity being contracted also varied. As explained before, that accounted (in part) for waiting lists varying around the country.

The new central system will mean that there is one standard set of service specifications; one standard list of which treatments may be funded; and agreed contract capacity with each clinic.

However, there will be no additional money.

This means that people living in areas that restricted referrals altogether, or funded very little, should see dramatic improvements.

It also means that people living in areas where more sophisticated and generous policies had been developed may see the clock going backwards.

As demand wasn't being budgeted for in some areas at all, the pooling of budgets is also likely to mean that the shortfall will have to be spread nationally.

This means that in some areas waiting times will come down (provided GICs have the capacity) whereas in other areas the waiting times may inevitably rise again. This is especially likely to happen as providers are only being promised consistency of income for one year. This means they will not be able to expand to offer more capacity unless the NHS CB permits them to.


The policies and service specifications which the NHS CB will use have been developed over the last year by parts of the existing specialised commissioning team, consulting with both clinicians and expert stakeholders.

The establishment of a Clinical Reference Group to help shape the service specifications has meant that, for the first time, clinicians had a say in the specification of what they would be asked to provide. On the whole this looks to have been a positive development.

The involvement of expert stakeholders in the process of developing the specifications has also had positive benefits. The process began with the best of the existing policy documents, although I am sure that people directly involved would say they could still be improved.

The establishment of that kind of consultation and involvement provides a route for evolving best practice from both sides.

Following the initial design of the service specifications, they were also put out to wider public consultation. That consultation is now closed; however you can access the draft specifications online. There are two documents: the specification of clinical services and the specification of surgical services.

How commissioning will work

For patient advocates to be able to work with the new commissioning system it is important to know a bit more about how it works.

Specialised commissioning falls into two parts. There is the formulation of policy and the accompanying service specifications.

Policy includes defining which parts of a patient's care falls within the definition of the specialised service and which parts are still the responsibility of local commissioners (CCGs). The NHS CB is quite clear from the outset about that dividing line, and about the responsibilities of local commissioners and doctors.

The split of responsibilities is defined in a document known as "The Manual for Prescribed Specialised Services".

For trans patients this is vitally important, as Primary Care has a big responsibility within the overall treatment process.

The pages you'll be interested in are pp126-128.

For Child and Adolescent services, CCGs have no part in commissioning at all. The service is designed around the one single nationally designated provider (The Tavistock and Portman NHS Foundation Trust) and the volume is anticipated to be around 130 patients each year. This means there should be no reason for GPs to get in the way of referrals. However, it also means that CCGs have no mandate to provide local alternative services (except to the extent of local Child and Adolescent Mental Health Services working in collaboration with the Tavistock and Portman as lead).

For adult services the Manual explains that two kinds of provider service are involved (GICs and surgery centres). For those who may have heard and been worried by rumours that there will only be three GICs the Manual makes clear that this is not the case. The Manual refers to seven designated GICs, plus four centres providing genital surgery and seven centres providing chest surgeries.

The Manual makes clear that CCGs are responsible for the initiation and ongoing prescribing of hormone therapy and for organising blood and other diagnostic tests as recommended by the Specialist Gender Identity Disorder Clinic Centres.

This part should help eliminate the problem which some patients have experienced, where PCTs had been "red-lining" hormone prescription (i.e. telling GPs they mustn't provide such prescriptions). As GP Practices are commissioned by the NHS CB, there is also a very clear line of authority for the commissioning team to address issues of bad practice among some GPs.

The actual leadership of commissioning will be centred in one of the NHS CB's Local Area Teams.

As explained before, the NHS CB will have 27 such LATs. Of these, ten (spread around the country) will have specialist commissioning responsibilities. One of these will therefore lead on the continuing development of the gender identity services. Patient advocates will therefore have one point of contact for this.

The ten LATs will divide up the actual contracting side of commissioning, in a way that is roughly analogous to the old Specialised Commissioning Teams.

Actual GIC and surgery services will be contracted by the LAT in which the service is located, using the national standard NHS contracts. The difference is that each LAT will deal with referrals for patients anywhere in the country. This means that if a patient moves whilst being treated, existing problems will not occur with continued funding. (Patients can, of course, opt to transfer to a closer GIC. Again, however, they are dealing with a single commissioning body.).


On the whole this is mostly good news.

The downsides identified so far are that some people will feel the effects of service options being levelled down. In Sheffield, for instance, the clinic had agreed (uniquely) with the commissioners in Yorkshire and Humber to fund facial electrolysis for Male to Female patients.

That treatment is not included within the new national service specification; therefore providers will not be reimbursed by the NHS CB (except where treatments have already begun).

The new specifications are also not yet aligned with the forthcoming national guidelines for care, which have been developed by an inter-collegiate committee for the Royal Colleges. This alignment will need to happen in due course; however it is unlikely there would be new money; therefore any extension of the service specification could only come through adjusting the numbers of referrals accepted each year, or by making services more efficient. The NHS CB will almost certainly push down the costs per referral and expect the clinics to find the savings they need to remain solvent.

The other issue mentioned in connection with the specifications is that they so far only describe one level of service for all. Gender patients are clearly very diverse. Therefore one way in which to permit fixed funding to go further (or even make savings) would be to develop a more flexible service specification to provide levels of care agreed between clinician and patient.


The big unknown is how care will be affected at the local level.

All the work in specification has concerned the details of specialist services (clinical and surgical) which fall within the specialised services definition.

As the "Manual" makes very clear, the NHS CB draws a sharp dividing line between what is specified to be funded centrally and what are regarded as "non-specified" services … the parts they don't fund.

The rule about prescribing and carrying out tests has been spelled out. However, there are large aspects of the local care pathway which remain unspecified, because they are outside of the specialised commissioning project.

What isn't clear from the documentation is whether patients will still need to be referred initially to Community Mental Health Services for initial assessment and referral. Financially, of course, it is in the interests of local commissioners to get shot of gender patients wherever they can. Trans people would probably mostly like to be referred straight to a GIC. If this change were suddenly to take place, however, it may have some undesirable effects on waiting lists and lead to people receiving less immediate care for depression that could be dealt with locally.

The possibility of other postcode effects could also exist where PCTs had formerly (in the good cases) provided services to support patients locally. On this, only time will tell.

In summary

What I have tried to do here is explain the most likely effects of what is going to be a complex change for the NHS itself.

Inevitably change creates worry for patients. I hope that, by explaining what we DO know, some of those worries will be reduced.

There are many unknowns still. In particular, we don't know how far the funding will stretch when spread nationally … and hence whether people will be able to access services quicker than in the past.

Some people may find that less things are covered than before. However, the benefits of having one set of commissioners to deal with, and involving both clinicians and expert patient stakeholders in policymaking, ought to have some benefits. Removing a big piece of discretion from local organisations should also eliminate a big problem for some.

As a strategist, readers will know that I am usually critical of the effects which this reorganisation of the NHS will have.

As someone expert in the commissioning of this kind of care, and in arguing for the improvement in care standards, I think that the benefits for trans people actually outweigh those disadvantages … only because the old system had enabled so many bad practices to exist.

Big changes are always unpredictable though. It is the things we can't foresee which have the habit of coming up and biting.

All I can say, therefore, is time will tell.

The appalling consequences of NHS privatisation explained

Ever since Andrew Lansley's white paper on transforming the NHS was first published in July 2010, many commentators have warned that the intentions were for the privatisation of the whole health system in England.

The problem with those warnings has often been the deniability. Go through the Health Act 2012, as eventually passed by Parliament, and the precise means by which the system would be opened up wasn't clear in black and white … if you could understand it at all.

Now, with the publication of vital regulations which set out the details of how commissioners must work, the tools are exposed. A petition calling for a Parliamentary debate on these regulations has achieved over 350,000 signatures.

Detailed explanation

In this video, Dr Lucy Reynolds, a Research Fellow at the London School of Hygiene and Tropical Medicine, explains in detail how the transformation will be achieved, how GPs are being groomed to take the blame, and what the impacts will be … based on similar experiences elsewhere. The interviewer is Jill Mountfield, a member of the steering committee on the “Save Lewisham Hospital” campaign.


Everyone below the age of retirement in England was born and has grown up in the NHS … and most of those in retirement were probably too young to really appreciate what life was like before it.

The presence of a publicly funded universal health service that is free and available to everyone at the point of need is so ingrained that most adult Britons take it for granted and have little appreciation of the extent to which they benefit.


Anyone who promises that they can reverse these changes once they have taken effect is mistaken, as I set out to explain in this piece last October. In particular, once you break up and sell off parts of such a complex system the state would find it very difficult to put back into public ownership as a whole.

As the song says, "Don't it always seem to go that you don't know what you've got till it's gone".

This is a long video … 75 minutes. If you're pushed for time then you will learn enough just in the first five minutes.

If you have more time though, this is the story which national broadcasters didn't explain at the time. You'll have plenty of time to ponder it when the NHS is irrevocably changed.

Thursday, March 14, 2013

GMC Interested in pursuing 39 transgender abuse cases


The General Medical Council, Britain's professional standards regulator for doctors, is interested to examine and possibly pursue up to 39 case histories involving the alleged abuse of transgender patients.

That was the headline announcement during a compelling presentation by businesswoman and trans activist Helen Belcher, appearing at a health care conference at the London Lighthouse earlier this week.

The cases, arising from a powerful twitter campaign thought up by Cambridge Liberal Democrat Councillor Sarah Brown in January this year, were part of a dossier of more than 130 detailed responses collected online following over 1000 tweeted patient complaints.

Documented case histories

98 of the documented allegations were presented to the GMC in mid February. Fifteen may have to be set aside for technical reasons.

The remainder … documenting serious alleged disciplinary issues, are now being examined more closely prior to actions being initiated.

Ten of the allegations involve alleged sex abuse or inappropriate intimate examinations.

Nineteen cases allege refusal of medical treatment.

One involves an alleged coercive threat of withdrawing treatment.

Four involve alleged inappropriate or damaging treatment.

And these, activists say, are probably only the tip of a far greater iceberg. These responses come only through those patients aware of the online campaign started on Twitter under the hashtag #transdocfail.

Previous research suggests there may be many more.

Wider care failings

The allegations come at a time when the whole medical profession and NHS system are coming to terms with the conclusions and recommendations of the Public Enquiry chaired by Robert Francis QC, dealing with the preventable deaths that occurred at Mid Staffordshire Hospital between January 2005 and March 2009.

Revelations of what took place in Mid Staffordshire have rocked the entire British health system.

The report documents that, between 2005 and 2009, warning signs of significantly higher than normal mortality rates at the Stafford Hospital were repeatedly ignored by managers and regulators. 

Patients were so thirsty they drank water from flower vases, relied on their families for food and were left in sheets soiled with urine and faeces.

Many suffered falls, some leading to serious injury, unobserved by staff.

The report states, "Staff treated patients and those close to them with what appeared to be callous indifference".

Francis writes,

"It is clear that not just the Trust’s Board but the system as a whole failed in its most essential duty –to protect patients from unacceptable risks of harm and from unacceptable, and in some cases inhumane treatment that should never be tolerated in any hospital".

And, among the conclusions the report states:

"The overarching conclusion is that ‘a fundamental culture change is needed to put patients first, which can largely be implemented within the system that has now been created by the new reforms".

Activists argue that this general observation, applied to the culture of the whole health system (which is now under scrutiny) is precisely what lies at the root of the cases documented to the GMC by trans people.

And a solution which does not include the same kind of scrutiny of these very serious alleged abuses, and the culture which has facilitated and has hidden them for possibly decades, would be suspect.

"If these terrible abuses aren't dealt with now", said one audience member in London, "we'll know that the NHS and doctors' organisations are still just painting over the cracks and indulging in a cover up".

Trans* Health Matters

Helen Belcher's presentation formed part of the Trans* Health Matters conference on 12th March 2013, funded and supported by the National LGBT Partnership and hosted by the Terrence Higgins Trust at their London Lighthouse centre in West London.

The conference was intended for Directors of Public Health, NHS and other commissioners, health and social care managers and practitioners, sexual health providers, education heads and (of course) Trans* patients and community members.

The event, Chaired by Monty Moncrieff, Chief Executive of London Friend, was packed.

I was invited to present a keynote speech setting the background and some challenges for the day … and, from beginning to end, the audience in the conference hall was standing room only.

Among the presenters were Lee Gale from the Trans Resource and Empowerment Centre and Trans Bare All; Jay McNeil of Traverse Research; Michelle Ross from cliniQ (a new health clinic for trans* people) and representatives from Trans Media Watch including Helen Belcher.

GP Obstructiveness

Jay McNeil presented details of a pilot research project which TREC had undertaken for NHS North West, attempting to install posters signposting supportive information in a sample of North West GP surgeries and gathering very basic anonymous summary data about trans patient numbers.

The signposting exercise was similar to the preliminary phase of an earlier NHS North West project with the Lesbian and Gay Foundation, which led to the development of a tool called 'Pride in Practice', endorsed by the Chair of the Royal College of GPs.

And the goal of the follow-up research with a sample of 200 GP Practices around the region was to provide very basic planning information for health leaders to design policies and strategic interventions.

As Jay explained (and as a forthcoming report will confirm) both halves of the research were derailed by serious obstruction on the part of practices, which included blatant lying by practice administration staff. This was in spite of the backing of the Strategic Health Authority and Local Management Committees.

The exercise was described by the Equality and Diversity team at NHS North West as a "Heroic Failure", insofar as it didn't achieve the original objectives because of the obstruction, but provided copious evidence of a culture problem among some GPs. The report will be published in the next couple of weeks and it will be reported here.

Obstruction causes direct harm

Jay McNeil's second presentation of the day concerned the largest research project to have ever examined the Mental Health of trans* people in Britain and Ireland.

The Trans Mental Health Study 2012 (report here) was run in Partnership with Transgender Equality Ireland between June and July 2012. It collected 889 responses from trans* people of all descriptions, obtained by snowball methods.

The research questionnaire incorporated a formal Mental Health inventory and produced high quality, academically robust and statistically significant findings of a kind not sourced on such a scale in Britain before.

Jay explained to the audience that the Mental Health inventory showed that the sample appeared to contain two distinct groups of people … almost exactly half with absolutely normal mental health and a second half with very distinct mental health problems which included severe depression and suicidal ideation.

Analysis of the data revealed that the healthy group corresponded mostly with those respondents who had completed their gender transition as they wished.

The group with mental health problems were those waiting for or encountering obstruction in obtaining gender identity treatment and support in transition.

The distinction could not have been more plain. Put simply, the research suggests that obstructing care for people with gender issues does them active mental harm.


Trans Media Watch is a group mainly concerned with the media representation of trans people. They aim to work with journalists and producers to help improve the quality and accuracy of coverage of trans* people.

Given this brief, the group explained that they wouldn't normally find themselves investigating health abuses … although the negative portrayal of trans people, and false press reports of what gender treatment costs, could be traced as a factor giving rise to discriminatory attitudes among clinical personnel.

Helen Belcher charted the background to the #transdocfail phenomenon. It had begun in the confluence of two otherwise unrelated press-related incidents in early January.

In the first instance there was a report by the Guardian's David Batty concerning the GMC's investigation of a popular private GP who provides care to trans people. This follow-up story in the same paper by Jane Fae explains the background and controversy which was generated.

At around the same time a quite separate controversy began, centred on comments by columnists Suzanne Moore and Julie Burchill. The intersection of these two controversies is explained in this Just Plain Sense blog at the time.

Frustrated that the big media story became the Moore / Burchill case, and that this had completely eclipsed concerns about the Guardian's highly selective reporting of GMC cases, Councillor Sarah Brown had begun a twitter hashtag for people to tweet bad experiences with Doctors. She called it #transdocfail.

The #transdocfail idea was an unexpected success … generating over 1,000 separate and distinct responses in barely 24 hours.

Breaking the silence

Sarah and I appeared on her local BBC radio station to discuss the phenomenon. You can hear the recorded discussion here.

Anecdotal tales related to many trans activists over the years  have long indicated that some trans people had negative experiences both with GPs and  gender clinic staff. In the past these reports couldn't be followed up, as the informants were afraid of the consequences of speaking out.

The anger generated by the combined sense of injustice over the two events seemed to cut right through that reserve though.

Suddenly it seemed that trans people were in a mood to tell their stories.

Some indication of those stories had been captured previously by questionnaire based research and the analysis of activist case files.

In 2006-7 the campaign group Press for Change was commissioned by the Equalities Review to conduct academically robust analysis of the problems faced in general by trans people. The report, "Engendered Penalties", published in February 2007, is available here.

The researchers reported:

The health care system of the UK is key to many trans people managing to fulfil their lives. Clearly for some the expertise, help and care they receive is very positive. Around 21% of trans people start the process by seeking help from a knowledgeable GP to begin the process of obtaining GRS, or other relevant services. However this research also found, that another 21% of respondents’ GPs either did not want to help, or in 6% of cases actually refused to help. This is an improvement of 50% compared with the experience of services over 15 years ago, but it still presents a considerable barrier. In the more general health care sector 17% of respondents had experience with a doctor or nurse who did not approve of gender reassignment, and hence refused services. Some 29% of respondents felt that being trans adversely affected the way they were treated by health care professionals.

At around the same time as this report was published, a report on a survey of GPs by the online service, showed that more than 80% of the 1,000 doctors whom they surveyed believed that trans people should not receive treatments on the NHS at public expense.

Given the findings reported above, the import of such attitudes is clear.

Helen Belcher's research

Helen explained in her presentation that the response to the #transdocfail hashtag begged for more detailed research to investigate the concerns that were being summarised in 140 characters. Without detailed research there would be many ways in which such responses could be dismissed.

She explained that in order to ensure complete confidentiality she had decided to set up a special survey on one of her own company's computers. And in order to do that she had had to register the system with the Data Protection Registrar.

She presented some of the original tweets


In spite of technical problems with the survey system she constructed, her more detailed online questionnaire elicited 130 completed responses.

Of these, as reported above, 98 documented allegations were presented to the GMC in February and the GMC has signified interest in pursuing 39.

There were, said Helen, a further 15 cases which the GMC felt unable to pursue, either because of the passage of time or because of limits in their jurisdiction (e.g. the doctors in questions weren't registered any more).

In addition, since the meeting with the GMC, Helen said that she had received another eleven reports.

Analysis from the responses indicated that:

  • 63% of people experiencing alleged abuse did not complain at all, because they didn't trust the system to give them fair treatment
  • 21% had had previous complaints dismissed
  • 39% of complaints related to GPs
  • 17% related to mental health services
  • 22% related to gender specialist services
  • 24% were not seeking trans* treatment at the time
Helen presented several quotes, these being a sample of the kind


Summing up

The audience listened intently to the presentation. Nobody ever likes to hear documented examples of doctors … professionals whom everyone should be able to trust … acting with such callous disregard for the vulnerable people turning to them for help and advice.

Some questioned Helen on how she would continue to carry out such research but I felt compelled to intervene. Clearly Helen had done her part by voluntarily setting up a system to collect evidence of this type … evidence which trans* people had hitherto felt too afraid and distrustful to report.

The evidence was plain … backed up by the preparedness of the GMC to pursue 39 out of 98 cases further … a remarkable indication of their strength.

Previous research also makes plain that there has been a serious culture problem among doctors, subjecting trans patients to "inhumane treatment" (to adopt the language of the Francis report).

I was at pains to stress that I'm sure the vast majority of doctors are not like this.

But I'm equally sure that if you probe a doctor who maltreats trans patients then you'll very likely find that they have a much wider attitude problem, affecting a far larger spectrum of the public.

Trans patients may just be better at flushing out such behaviours, as those disposed to bullying and abuse may feel greater impunity and cover their tracks less well.

So passing this off as a problem for a trans businesswoman to research in her spare time is not an acceptable strategy.

And dismissing these cases as being secondary to the issues thrown up by the Mid Staffs case would also be adding to a problem rather than dealing with it.

The evidence is part of the wider cultural problem identified by Francis. And it is the job of the regulators, professions, and NHS commissioners contracting such doctors to deal with it … not a patient group.

It is clear where the buck stops. Now, it is time to deal with the medical profession's dirty linen.