Trans delegates at a consultation forum on NHS Gender Identity Services (GIS) were smiling and talking of 'Positive Vibes' at the end of a long day of participative discussions and presentations on service commissioning reform in London yesterday.
The meeting, facilitated by NHS England's Patients and Partnerships team, in conjunction with the Equality team and Specialist Commissioning leaders, involved over fifty stakeholders.
The event was designed to explain both the interim arrangements for commissioning GIS in England, and the process that will follow to develop an all new service specification and protocols for implementation in April 2014.
A significant part of the time was also spent gathering views … although, unusually for such occasions in the past, the leaders present gave the strong impression that they had already absorbed and understood many of the areas of contention.
The conduct of the event, which took place at the Coin Street Neighbourhood Centre near London's South Bank, appears to confirm the promises of a new kind of approach to stakeholder involvement under the new regime.
As one delegate observed to me, "the atmosphere could not have been more different compared with the event organised last year by the Department of Health under the Government Equality Office's Transgender Action Plan".
One civil servant had described their experience at that meeting last year as "bruising". And you could understand why delegates to yesterday's event may have been anticipated the proceedings with cynicism.
There were no raised or angry voices on this occasion though, as stakeholders and NHS England staff alike threw themselves into the work with gusto.
The event was attended for five hours by Professor Steve Field, NHS England's Deputy Chief Medical Officer, who also has a cross-cutting responsibility overseeing work on Health Inequalities and Equality.
Field is a GP (he still practices one day a week in Birmingham). He was the previous chair of the Royal College of General Practitioners (RCGP) and wrote the organisation's curriculum for the training of GPs. He is also a keen advocate of the NHS Constitution and quoted the opening passage when speaking in the afternoon:
The NHS belongs to the people. It is there to improve our health and wellbeing, supporting us to keep mentally and physically well, to get better when we are ill and, when we cannot fully recover, to stay as well as we can to the end of our lives. It works at the limits of science – bringing the highest levels of human knowledge and skill to save lives and improve health. It touches our lives at times of basic human need, when care and compassion are what matter most.
Field was joined by NHS England's Head of Specialised Commissioning, Kate Caston; the Portfolio Director for Mental Health, Patrick Neville; and gender clinician Dr John Dean, recently appointed to chair the Clinical Reference Group (CRG) for Gender Identity Services.
Also present was Professor Dinesh Bhugra, who is President of the World Psychiatric Association (WPA) and a former President of the Royal College of Psychiatrists. He is Professor of Mental Health and Cultural Diversity at the Institute of Psychiatry in London. His attendance confirmed the level of engagement now in the processes of reform.
NHS England is responsible for direct national commissioning of over 150 so-called 'Specialist Services'. These are clinical specialities where the relatively small size of the patient population, the cost profile, or the specialised concentration of clinical expertise means that it would not be sensible for local Clinical Commissioning Groups (which replaced Primary Care Trusts) to each contract services.
The purpose of CRG's is to review and improve the delivery of these specialist services, which includes refining the specifications for purchasing such services from provider clinics. NHS England currently has 74 such CRG's, which were initially set up in 'shadow' form in 2012, so that NHS England would have policies in place to take over commissioning these services in April 2013.
One of those 'shadow' CRG teams had engaged with trans stakeholders over the last year to develop an initial national policy for Gender Identity Services. They based their work on the policy used in the East Midlands, thought to be among the best. The product of their work was the draft English Service Specification (ESS) which had been put to full public consultation in January 2013.
It was explained that the reason why that 'ESS' had not been adopted from 1st April was because of the strength of stakeholder feedback received.
Reports say that, of all the 150+ policies consulted upon in January 2013, more than 80% of the feedback had concerned the GIS documents, and had come from trans stakeholders.
Thus, one important purpose of the meeting was to explain the policy which it was proposed to adopt for the interim, based on the service specification recently developed by NHS Scotland, with a few specific changes. It was proposed to introduce this interim policy from 1st July 2013.
It was this and other proposed changes which had already provoked howls of concern from clinicians in some of the English Gender Identity Clinics, which I reported a couple of weeks ago.
The NHS England team will be meeting the clinicians on 21st June to discuss the same proposals. As Steve Field commented, "The process may be rocky at times and clinicians may find the change difficult".
Steve Field explained that, having bought time by implementing an interim service specification and protocols from 1st July, the main work of the Clinical Reference Group would be to embark upon a detailed review, aiming to present a new set of proposals to stakeholders by January 2014 and implement those new policies from April the same year.
He explained that he had heard some of the concerns voiced during this event around existing services, acknowledging worries about the safety of the location of one clinic, and the present differences in accessibility to services in different parts of the country. He was also familiar with all the feedback from the January consultation.
His ambition, he said, was to achieve uniformly high standards across England, although he acknowledged that it couldn't be guaranteed that everything that people wanted could necessarily be funded by the NHS. "We will consult to learn", he promised.
Field made clear his view that all GIS clients had the right to be treated with dignity, care and compassion … adding, "We need to find a way of detecting early where that's not happening".
He expected lots of patient input to the CRG's design work. "We want to design a service that's the best in the world".
The Scottish connection
John Dean presented a potted version of the proposed interim specification, highlighting the four areas of difference between this and the Scottish Service Specification (SSS) on which it is based.
The details will be covered in a subsequent blog once the meeting with clinicians has concluded on 21st June. They concern details such as how referral takes place; the expected pathways within a service; which kinds of treatments are available to be funded; and the order in which some things can occur.
NHS England have also promised to release all of the presentations and captured workshop comments from the event.
One headline to be going on with is that the new interim policy will permit referral direct from any General Practitioner or other clinical service into any of the GIC services that are commissioned in England.
Although GP referral already happens in some parts of England, it is far from the norm. Accommodating it may be one of the biggest practical changes which existing clinics need to adjust to. However there are clear benefits for patients, who will no longer need to be referred through their Community Mental Health Team in the first instance, and will also have a much wider choice of clinics to attend.
It is concerns about changes like this that have some of the clinicians in uproar, as reported before. And it is hard to tell at present how much of the clinical antipathy stems from hearsay and speculation, and how much that may be dissipated in the course of Friday's event by talking through and understanding the proposals.
Whatever the mood of the clinicians, however, the NHS England team were leaving no doubts of their own determination about reform. The seniority and experience of some of the figures involved means that objections would need to be very well founded. At the end of the day it is NHS England who will be purchasing and contracting services and there were hints of an attitude that if some providers didn't want to offer services in the form the commissioners wanted then then they could be decommissioned.
Open to innovation
John Dean also expressed a willingness to look at ways of innovating to develop better services. He said he was in favour of looking at ways of delivering more elements of the services locally and there will be active discussions about how NHS England might be able to cover facial hair removal for some patients (only available in some areas till now).
The interim proposals had already prompted new questions. One delegate asked whether patients could be referred from private clinicians into NHS services. Another queried whether patients could be referred back at later stages following an initial treatment episode … for instance, where someone might have been deferred a decision about gender reassignment surgeries after transitioning socially but then decided, years later, to pursue that. Others wanted to know whether, if facial hair removal were to be funded now, past patients (who could not afford to purchase such treatment themselves) could return seeking such help.
Questions like these underline how change often raises new questions at the same time as trying to resolve old ones.
Update 21st June 2013
The meeting of clinical leaders of the English Gender Identity Services and NHS England's specialist commissioners took place on Friday 21st June 2013, as planned. Multiple sources have confirmed that the meeting was constructive and successful. In discussions, which included the opportunity to learn about the Scottish approach in more detail, the clinicians are understood to have found the necessary changes less of a concern than previously feared, and were able to agree to operate with them as required. This means that the interim protocols will commence from 1st July 2013 as expected. It is understood that the discussion may have also highlighted concerns which the clinic leaders themselves have had concerning the capability, knowledge and professional behaviours of some general practitioners. The capabilities of GPs are an even more important issue in a system where they are responsible for direct referral. It is therefore vital to bear in mind that this is only the very first step in a change process, where both clinicians and patients have a stake in seeing things change for the better. There will be much work for NHS England the specialist commissioners to do in order to address the whole environment in which this kind of care pathway operates. NHS England have committed to providing written up details of both meetings so far.