NMCN Annual Report€¦ · Development of a Competency Framework (objective 2019/20-08) has been progressing through a sub-group set up and led by Dr Ben Hall (Scottish Clinical Leadership

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National Gender Identity Managed Clinical Network Scotland

ANNUAL REPORT 2019-20

V1.0

Lead Clinician: David Parker

Programme Manager: Aileen Ferguson

Programme Support Officer: Luke Rush

Data Analyst: Hugh O’Pray

National Gender Identity Clinical Network Scotland (NGICNS): Annual Report 2019/20

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Contents

1. Executive Summary .................................................................................................................................. 3

2. Introduction ............................................................................................................................................... 3

3. Report on Progress against Network Objectives in 2019/20...................................................................... 3

3.1. Effective Network Structure and Governance ..................................................................................... 4

3.2. Service Development and Delivery ..................................................................................................... 4

3.4. Education ........................................................................................................................................... 5

3.5. Audit and Continuous Quality Improvement ........................................................................................ 6

3.6. Value .................................................................................................................................................. 7

4. Plans for the Year Ahead .......................................................................................................................... 3

5. Detailed Description of Progress in 2019/20 ............................................................................................. 4

6. Proposed Work Plan for 2020/21 ............................................................................................................ 10

Appendix 1: Steering Group Membership ................................................................................................... 14

Appendix 2: Finance ................................................................................................................................... 16

Appendix 3: Network Progress against Review Priorities ............................................................................ 17

Appendix 4: Network Progress against ScotPHN Priorities ......................................................................... 20

Appendix 5: Data ........................................................................................................................................ 26


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1. Executive Summary The network has worked hard in 2019-20 on a variety of fronts, working with NHS England and Wales in supporting the commissioning of a new surgical contract and non-surgical gender services, collecting and further refining waiting times data, responding to queries from Government, NHS staff and service users, and developing guidance, e.g. on hair removal services, publishing newsletters, holding our first ‘Virtual MDT’ and beginning work on a competency framework for gender staff. More details of our work can be found set out in this report, and, as ever, we welcome feedback on all aspects of what we do.

A significant concern to the network is that of waiting times to access gender identity clinics in Scotland. There are critical gaps in resource to offer assessment to both young peoples’ and adult services. The network is supporting the work of the YP service to gain national designation as a specialist service. A key issue for adult services is suitably trained clinicians to offer initial assessment. The network is working to develop a competency framework for gender staff with a view to increasing accessibility of services and supporting a reduction in waiting times.

Since February 2020, NHS Scotland’s priority has been managing COVID-19 and this has seen clinical and other resources diverted from network activity. The network has undertaken an exercise to capture the impact of this unprecedented situation on the current reporting period and to assess the likely impact on delivery of the 20/21 workplan. It is clear that the situation is subject to change.

2. Introduction The National Gender Identity Clinical Network Scotland (NGICNS) was established in May 2014. The need for the network had been recognised in a Scottish Needs Assessment Programme (SNAP) report in 2001 that highlighted a lack of published data, haphazard access to treatment and ‘an absence of funded gender dysphoria services in Scotland for individuals with gender dysphoria.’

In 2012 Scottish Government published the Gender Reassignment Protocol (GRP). Following this, NGICNS was commissioned to bring together primary care, patient and third sector representation with the country’s four gender identity clinics (GICs) and other gender identity specialists to facilitate the implementation of the GRP across Scotland and to achieve a co-ordinated provision of gender care; improving access to and quality of gender identity services. The network has since worked hard to gather robust waiting times data, surgical referrals data, produce information leaflets, newsletters and guidance for NHS Boards (for example on endocrinology and hair removal), and to take part in regular education and engagement sessions with NHS staff, service users, and other stakeholders. These, and the network’s other activities in the 2019-20 reporting year, are detailed in this report.

3. Report on Progress against Network Objectives in 2019/20 National networks have agreed core objectives that reflect the Scottish Government’s expectations for managed clinical networks, as described in CEL (2012) 291. The network’s core objectives are:

Design and ongoing development of an effective Network structure that is organised, resourced and

governed to meet requirements in relation to SGHSCD Guidance on MCNs (currently CEL (2012)

29)

Support the design and delivery of services that are evidence based and aligned with current

strategic and local and regional NHS planning and service priorities.

Effective Stakeholder Communication and Engagement through design and delivery of a written

strategy that ensures stakeholders from Health, Social Care, Education, the Third Sector and

1 Please see: https://www.sehd.scot.nhs.uk/mels/CEL2012_29.pdf

https://www.sehd.scot.nhs.uk/mels/CEL2012_29.pdf


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Service User are involved in the Network and explicitly in the design and delivery of service models

and improvements.

Improved capability and capacity in gender care through design and delivery of an education

strategy that reflects and meets stakeholder needs.

Effective systems and processes to facilitate and provide evidence of continuous improvement in

the quality of care (CQI).

Generate better value for money in how services are delivered.

This report gives an overview of progress against these objectives in the year 2019/20.

3.1. Effective Network Structure and Governance

The network appointed its current Lead Clinician, David Parker, on 1st September 2018, for a three year term. The Steering Group met four times within the reporting period (objective 2019/20-01). In 2018 The Steering Group membership was reviewed (objective 2019/20-02) and extended to include an advanced pharmacist, to better reflect the patient pathway and help advise the group on the prescribing, licensing and formulary queries that arise with regard to the prescribing of hormones. The Steering Group remains multi-professional, with input from Scottish Government, medical, nursing, Allied Health Professional (AHP), third sector and support groups. The network has sought to co-opt a planning manager from a territorial NHS board on to the Steering Group (Review Recommendation1), and wrote to Colin Briggs, Chair of the Directors of Planning to ask for a nominee in March 2020. Any response is likely to be delayed at present due to the Covid-19 situation. A full note of the membership of the NGICNS Steering Group can be found in Appendix 1.

3.2. Service Development and Delivery

The Steering Group has a standing item relating to service delivery, and has assisted NHS Boards in their funding bids for gender services, with job descriptions shared to reduce duplication of effort and help build a more consistent approach, where appropriate, to service provision. Benchmarking across centres (e.g. with regard to clinical sessions or whole time equivalent (w.t.e) was carried out. Waiting times data continue to be monitored and improved to inform recruitment and service development – see 3.5 below and Appendix 5. From January 2019 each centre was asked to provide additional actual waiting times data to the network. It was also deemed useful to gather data on forecast waiting time for each centre (this is a subjective figure but is communicated to newly referred patients, to allow them a better idea of when they might be seen). Since quarter two of 2019-20 each centre has provided additional waiting times data.

Surgical referral data is also now reported in graph format; more details of the increasing demand on all services can be seen the Appendix. Concerns brought to the network by service users with regard to pathways of care were passed on to the relevant local service. Colleagues within the National Services Division’s specialist services team are now taking forward the application for designation of a Scottish chest reconstruction surgical service (objective 2019/20-03), building on previous work done by the network to gain the views of surgeons across Scotland. The network also works closely with colleagues in NSD’s specialist services department on arrangements around gender reassignment surgical services in England. NGICNS assisted with NHS England’s commissioning processes for surgery and gender identity clinics by collating and making available on the NGICNS website the list of surgical providers and their referral contact details, which is of benefit to all gender clinics in the UK, and by clinical staff sharing their expertise as part of the commissioning process.


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NGICNS assisted staff in the Sandyford Children and Young Person’s Service in their stage one application for Specialist Service Designation in Spring 2019 (objective 2019/20-04), which was accepted by National Specialist Services Committee (NSSC) in March 2019. The network is facilitating a meeting between South East of Scotland and West of Scotland Paediatric Endocrinologists in May 2020, and which will help define the patient pathway in advance of the service submitting a stage two and three application, although this work may take longer than anticipated due to Covid-19 restrictions. The network met once again with NHS Board Equalities leads in January 2020 (objective 2019/20-05), with the Clinical Lead and Programme Manager highlighting the work of the network and the Service Mapping exercise, and aiming to foster a constructive and supportive dialogue with the Board leads to assist service improvement. Work also took place with colleagues from the Prisoners’ healthcare network around the safe transfer of prisoners. 3.3. Stakeholder Communication and Engagement The network continues to receive a large number of contacts from members of the public, service users, MSPs, NHS staff and journalists, in addition to Freedom of Information Requests and Parliamentary Questions, on a wide range of topics, including: surgery, service provision, endocrinology, wigs, hair removal, waiting times, CHI change, gender recognition certificates and terminology/language, and these queries were dealt with in line with NSS processes. The lead clinician attended a session with young people in Selkirk in the Borders on 10/03/2020, which went very well. Links were made with Crew 2000, a drugs awareness organisation, in May 2019, and

communications reassuring service users that some services were still in place for them were developed and distributed in tandem with LGBT Youth. The leaflet providing information for adult gender clinic service users (objective 2019/20-06) was circulated to clinical staff across Scotland for a final proof-read prior to printing. A first newsletter (right) for NGICNS was published, with another one in draft form scheduled for May / June 2020. The network’s Communications and Engagement strategy was updated for 2019/20.

3.4. Education

Details of the Royal College Physicians gender qualification (objective 2019/20-07) were shared with the steering group in May 2019 prior to the first intake of the course in 2020. The network is on the mailing list and will publicise subsequent intakes – the course is due to recruit again in September and October 2020. Development of a Competency Framework (objective 2019/20-08) has been progressing through a sub-group set up and led by Dr Ben Hall (Scottish Clinical Leadership Fellow). There have been two meetings of the sub-group to date and a draft format has been agreed for the competencies. Cervical screening - amendments to the smear takers’ protocol were passed to screening colleagues in October 2019. The network also engaged with NHS Inform and NHS Health Scotland and assisted with updating both the NHS Inform Trans screening health pages, and the cervical screening leaflets, to ensure they were more inclusive for trans and non-binary people.


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A ‘Virtual’ Multi-disciplinary Team (MDT) has been piloted and worked well, with staff from all the GICs across Scotland taking part, which was used to discuss complex cases, share expertise, and encourage an open dialogue between staff from different centres. David Parker has presented, in some cases with network colleagues, at the British Association for Sexual Health and HIV meeting (May 2019), the Faculty of Sexual and Reproductive Healthcare (May 2019), with an NHS Scotland Chaplain at the Just Festival (August 2019), the Royal College of Psychiatrists (September 2019), the British Association of Gender Identity Specialists (Oct 2019), to Nursing students from Queen Margaret University (January 2020), to NHS Fife Psychologists (February 2020), at Borders Grand Round (March 2020) and at the Practice Nurse update (March 2020). In addition to presenting to NHS colleagues, network colleagues have responded to queries from Scottish Government (Ministerial Correspondence), and attended local trans stakeholder groups. The network lead also attended the European Professional Association for Transgender Health (EPATH) meeting.

Unfortunately, attendance at Edinburgh University Endocrine Society (March 2020) was curtailed due to COVID-19 restrictions.

The network’s Education strategy was updated for 2019/20.

3.5. Audit and Continuous Quality Improvement

The exercise of mapping gender services in Scotland exercise was completed (objective 2019/20-09 and Review Recommendation 2) and the draft report taken to the Equality and Diversity Leads for the NHS Boards across Scotland, with the offer extended by the network to assist any Boards with the planning of services, particularly for patients while they wait for a first appointment at a gender identity clinic. However, some of the barriers to providing services are financial, and NGICNS is in an early stage dialogue with data modellers at NHS Education for Scotland to scope out what might be a realistic workforce to meet demand for gender services. The network has also been tasked with progressing the Review and Scottish Public Health Network (ScotPHN) recommendations (Objective 2019/20-10). Further detail can be seen in Appendix 3 & Appendix 4. With regard to the review recommendations, as noted in Section 3.1, the network has written to seek planning representation on its steering group (Review Recommendation 1). Work is ongoing on how to manage data collection within the Gender Identity Clinics using the National Sexual Health (NaSH) IT system around collecting key performance indicators for gender, and this work will

continue in 2020/21 (Review Recommendation 3). Engagement sessions with Primary Care colleagues have continued (Review Recommendation 4), with presentations, including to the Edinburgh University GP society (February 2020). Unfortunately, the March session to Edinburgh University was cancelled due to Covid-19. The Lead Clinician, and local colleagues, has met with GP advisors and representatives to discuss more formal arrangements for ongoing care including a shared care agreement. NGICNS has worked to increase awareness of services outwith the central belt. Unfortunately, the service user event planned for Dundee in April 2020 has been cancelled due to the Covid-19 risk (Review Recommendation 5), however, network staff attended the Scottish Trans Alliance conference, and have started issuing newsletters to our stakeholders. The network has an up to date communications plan.

As noted in section 3.2 and 3.5 above, the network completed the service mapping exercise (Review Recommendation 6), and is working to cost out what additional services might be required to meet patient demand in the short and longer term on a national basis.

NGICNS has updated its designation objectives within the Service Agreement (Review Recommendation 8).


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Review Recommendation 7 tasked the network with making progress with the recommendations from the ScotPHN needs assessment report. With regard to the ScotPHN recommendations, Objective 1 was to ‘consider alternative models of care for gender identity services to support the development of multidisciplinary, person-centred approaches which reduce variation, including the potential for additional local provision of both specialist and support services within the NHS, additional involvement of primary care services, additional involvement of community and voluntary sector in service provision, and centralised commissioning of additional services e.g. hair removal.

The network queried whether national commissioning for hair removal would be possible, but was advised that such a move was unlikely. Accordingly, the network developed guidelines for facial hair removal for NHS Boards (right)

which is available here: https://www.ngicns.scot.nhs.uk/wp-content/uploads/2020/04/Facial-Hair-Removal-Guidelines-for-NHS-Boards-re.-Transgender-Patients-v1.0.pdf It has also been linking in with NHS Education for Scotland’s workforce modelling team to scope modelling different options to deliver care within GIC settings. The GICs already share, through NGICNS, several different models of care, some of which include voluntary service counselling input. The second recommendation concerns ensuring gender identity services are adaptable to changes in the trans population presenting to GICs. The network has made progress against this objective. There is access to email support through the NGICNS website, in addition to a feedback option for service users. Some gender identity clinics in Scotland contract formally with Third sector organisations, for example for counselling services, and links between GICs and the third sector are reinforced at the NGICNS Steering group. The network highlights the needs of non-binary and gender diverse people in its work, for example when providing advice on screening services in advance of the launch of revised screening information in Scotland in April 2020. The network’s Quality strategy was updated for 2019/20.

3.6. Value

The network distributed guidance to clinicians in Scotland on NHS England’s progress in setting up a national referrals centre (objective 2019/20-11). In advance of national guidance from England, the network collated and published information on all UK surgical providers including surgery type, contact details and surgeon information. This was subsequently shared with colleagues in NHS England and is used as a discussion aid with service users.

During the 12 month period, NGICNS’ Lead Clinician and other staff have engaged with a large number of clinical staff, service users and other stakeholders (objective 2019/20-12). More details can be found in section 3.4.

With regard to review of the Gender Reassignment Protocol (2019/20-13) It was agreed that this should be taken forward when the new World Professional Association for Transgender Health (WPATH) Guidance is issued (likely to be towards the end of 2020.) This has been incorporated in the 2020/21 workplan.

The NGICNS website has been under ongoing review (objective 2019/20-14) with updates and improvements made throughout the year. We implemented a ‘join our mailing list’ option, as well as a feedback form, which has helped us improve what we offer. We have also added information on hormone availability, gender reassignment surgery providers and on service delivery during Covid-19.

Statistics for the NGICNS website are noted below. Page views and sessions have increased three-fold, as has visits to the home page. The page most frequently visited is the one housing the details for the GICs; this has been accessed twice as frequently as in 18-19.

https://www.ngicns.scot.nhs.uk/wp-content/uploads/2020/04/Facial-Hair-Removal-Guidelines-for-NHS-Boards-re.-Transgender-Patients-v1.0.pdf




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These figures may reflect an increased awareness of the network, along with an increased amount of information being posted on the website.

Note: A ‘session’ is a group of user interactions with your website that take place within a given time frame, for example a single session can contain multiple page views, events, social interactions, and ecommerce transactions.

A ‘pageview’ (or ‘pageview hit’, ‘page tracking hit’) is an instance of a page being loaded (or reloaded) in a browser. Pageviews is a metric defined as the total number of pages viewed.


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4. Plans for the Year Ahead In response to the Covid-19 restrictions, the NGICNS website has been constantly updated, including with information around hormone availability and GIC services. The NGICNS website will continue to be reviewed and improved for use by service users and colleagues. In terms of published documents, NGICNS will publish and distribute the Adult information leaflet and produce a draft Competency Framework for gender interventions by the end of March 2021. The network is also pleased to be contributing to work with NHS Lothian and a media company ‘Hee Haw’ on further information films on fertility preservation and hormones. These have been identified as areas where it would be helpful to be able to provide more information to service users, to allow them to consider the right choices for them in advance of any decision making, and will support informed consent. It is anticipated that these pieces of work will continue despite the pandemic response. It is acknowledged that the situation is subject to change and if the lead clinician were to be redeployed, the status would require to be reviewed.

The Steering Group plans to support potential changes to the Gender Reassignment Protocol following publication of WPATH Standards v8, this will be reviewed on publication of the Standards and on consultation with Government colleagues. The Network will also explore gathering performance data from the National Sexual Health IT System (NaSH) which is a computer system used by NHS boards for managing sexual health records, to ensure there are standards against which services can be measured, by March 2021. It is also important that we support colleagues in taking forward proposals for national designation for C&YP service and surgical services in Scotland, where required.

The network will continue to engage with the community across Scotland through a variety of media, to ensure that service users are aware of, and inform, the future work of the network.

Some network activity (face to face engagements and meetings requiring clinician input) have been suspended due to re-deployment of clinical staff to other roles and lack of capacity to contribute.


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5. Detailed Description of Progress in 2019/20 Insert updated Annual Workplan here, detailing their status as of 31 March of the reporting year. All network initiatives/projects mentioned in section 4 of the report must be listed in the Annual Workplan.

NGICNS Workplan 2019/20 – Update as at 31st May 2020

RAG status key:

RAG status Description

RED (R) The network is unlikely to achieve the objective/standard within the agreed timescale

AMBER (A) There is a risk that the network will not achieve the objective/standard within the agreed timescale, however progress has been made

GREEN (G) The network is on track to achieve the objective/standard within the agreed timescale

BLUE (B) The network has been successful in achieving the network objective/standard to plan

The Institute of Medicine’s six dimensions of quality are central to NHS Scotland’s approach to systems-based healthcare quality improvement, therefore objectives should be linked to these dimensions:

1. Person-centred: providing care that is responsive to individual personal preferences, needs and values and assuring that patient values guide

all clinical decisions;

2. Safe: avoiding injuries to patients from healthcare that is intended to help them;

3. Effective: providing services based on scientific knowledge;

4. Efficient: avoiding waste, including waste of equipment, supplies, ideas, and energy;

5. Equitable: providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location or

socio-economic status; and

6. Timely: reducing waits and sometimes harmful delays for both those who receive care and those who give care.


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Objective Number

Strategic Objective Planned start/ end dates

Detailed Plan Available / Owner

Description of progress towards meeting objective as at 31/10/2019

Outcome / evidence RAGB status

1. Effective Network Structure and Governance [linked to Quality Dimensions 3,4,5,6]

2019/20-01

Steering Group will meet four times within the twelvemonth period, with subgroups convened as required

01/04/2019-31/03/2020

Steering Group and subgroup member-ship

NGICNS is on track to meet this target. It met in April and September, with a September meeting scheduled for 2019 and further 2020 meetings being arranged at the time of writing. Sub-group and ad hoc meetings are convened as required to take forward the workplan

Delivery of the NGICNS network workplan to ensure improvement in patient care

(B)

2019/20-02

Steering Group will review their membership at July’19 NGICNS meeting

01/04/2019-31/03/2020

Steering Group

This was deferred due to the amount of business requiring to be covered, and was considered at the February 2020 meeting

Membership reflects the patient pathway and brings suitable expertise to enable informed discussion and allow actions to be taken to improve patient care

(B)

2. Service Development and Delivery [linked to Quality Dimensions 1,2,3,4,5,6]

2019/20-03

NGICNS will 1) clarify patient pathways for surgical services previously managed via the AEARP and 2)

01/04/2019-31/03/2020

NGICNS Steering Group

A meeting of relevant individuals was arranged and the network, with colleagues from commissioning, are progressing arrangements around non-GRS

NHS staff across Scotland will have access to clear advice about referral

(B)


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Objective Number





facilitate scoping a potential Scottish feminising surgical service

surgeries and the potential for a Scottish surgical service. This was then passed to Commissioning colleagues to progress. This is no longer an action for the network

procedures for specialist surgeries

2019/20-04

NGICNS will facilitate and support the application for Specialist Service Designation by Sandyford C&YP Service, Spring 2019

01/04/2019-31/03/2020


At present, the network has taken this as far as is possible. NHS GG&C asked for a pause on this piece of work at present. This was passed to Commissioning colleagues to progress. This is no longer an action for the network

Sandyford service will be kept informed of the required next steps in the application process, submitting an application on time to the policy groups

(B)

2019/20-05

Engagement with NHS Board Equalities leads in November 2019

01/04/2019-31/03/2020


NGICNS presented the results of the Service Mapping and information about the network to the Board Equalities leads at their meeting in January 2020

NGICNS will meet with the Equalities Leads, highlighting the results of the service mapping exercise, and offering support in addressing gaps

(B)

3. Stakeholder Communication and Engagement [linked to Quality Dimensions 1,3,4,5,6]


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Objective Number





2019/20-06

NGICNS will publish and distribute the Adult information leaflet in the 19-20 reporting year

01/04/2019-31/03/2020

Leaflet Sub-Group

This has now been sent to clinical colleagues for review but publication may be delayed until the next reporting period.

Adult service users will be provided with an up to date information resource about GIC services in Scotland

(A)

4. Education [linked to Quality Dimensions 1,2,3,4,5,6]

2019/20-07

NGICNS to share with GIC staff across Scotland the details of a gender qualification, when available

01/04/2019-31/03/2020

Lead Clinician

Information from the Royal College of Physicians was distributed and will continue to be shared with each new intake to the course

Staff will be informed about current educational opportunities relevant to their specialist role

(B)

2019/20-08

NGICNS will consult and produce a draft Competency framework for gender interventions

01/06/2019-31/03/2020

Lead Clinician

NGICNS is engaging with colleagues at NHS Education who have worked on a similar competency framework

Staff will be informed about key skills and training relevant to their specialist role and level of experience

(A)

5. Audit and Continuous Quality Improvement [linked to Quality Dimensions 1,2,3,4,5,6]

2019/20-09

On completion of the service mapping exercise, NGICNS will, throughout the reporting year, contact NHS Boards and regional planners to highlight areas where there is currently no clear referral pathway for patients, e.g. lack of

01/04/2019-31/03/2020


The report was taken to the Board Equalities leads in January 2020

Boards will be provided with a report on where they are not supplying services to patients, and will be offered support by the network

(B)


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Objective Number





provision of wigs, and NGICNS will offer to work with the Boards to find solutions to these gaps in service.

on how these gaps may be addressed.

2019/20-10

NGICNS will make progress against the outstanding objectives of the ScotPHN and Expert Review

01/04/2019-31/03/2020

Steering Group

These are noted in Workplan 2 below

Steering Group to continue to make progress against review recommendations, building specific items into the workplan throughout 19-20 as required

(G)

6. Value [linked to Quality Dimensions 1,2,3,4,5,6]

2019/20-11

NGICNS will provide GIC staff with guidance re. sending referrals to national referral management service in England, within the reporting year

01/04/2019-31/03/2020


All guidance from NHS England has been passed on to clinical staff, and the network website has incorporated information for patients and clinical staff

GIC staff will have guidance to ensure referrals are correct, minimising delay to patients and re-work

(B)

2019/20-12

NGICNS will engage with community and professional groups – via a range of educational and consultation events

01/04/2019-31/03/2020


NGICNS has presented at the British Association for Sexual Health and HIV meeting (May), the Faculty of Sexual and Reproductive Healthcare (May), EPATH (April), British Association of Gender Identity Specialists (Oct) and linked with

NGICNS will continue to raise its profile – reaching a wider group of stakeholders to share information for mutual benefit

(B)


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Objective Number





Crew 2000 (May) and NHS Scotland Chaplains (August), The Just Festival (August), Royal College of Psychiatrists (September), in addition to NHS colleagues, Scottish Government (Ministerial Correspondence), and local trans stakeholder groups. These sessions will continue throughout the year

2019/20-13

Steering Group will consider appropriate actions that will support potential changes to the Gender Reassignment Protocol

01/04/2019-31/03/2020


It was agreed that, as a result of the second consultation on the GRP, this item should not be taken forward at this time, instead it should be linked in with publication of WPATH SoC V8

Scottish legislation will be up to date and relevant to the community it services

(A)

2019/20-14

The NGICNS website will be reviewed and improved to provide a richer resource for Service users and colleagues in Primary and Secondary Care

01/04/2019-31/03/2020


The network is linking in with Primary Care colleagues to draft pages for GPs and Primary care staff that will pull together all useful resources in one place

NGICNS website will be up to date, useful and relevant to the community it serves

(A)


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6. Proposed Work Plan for 2020/21


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Objective Number





2020/21-01

NGICNS will publish and distribute the Adult information leaflet in the 2020/21 reporting year

31/03/21 Aileen Ferguson

Adult service users will be provided with an up to date information resource about GIC services in Scotland

2020/21-02 NGICNS will consult and produce a

draft Competency framework for gender interventions by the end of March 2021

31/03/21 Ben Hall

Staff will be informed about key skills and training relevant to their specialist role and level of experience

2020/21-03

Steering Group will consider appropriate actions that will support potential changes to the Gender Reassignment Protocol following publication of WPATH Standards v8 (date dependent upon publication)

31/03/21 Steering Group

Scottish legislation will be up to date and relevant to the community it services

2020/21-04

The NGICNS website will be reviewed and improved to provide a richer resource for Service users and colleagues in Primary and Secondary Care by March 2021


NGICNS website will be up to date, useful and relevant to the community it serves


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2020/21-05

Network to explore gathering KPIs from Nash to ensure there are standards against which services can be measured, by March 2021

31/03/21 Steering Group / IMS

KPIs will provide measurable standards which can be audited against to provide baseline and improvement data, to be used to support Boards in providing a more equitable service

2020/21-06

Network to work with Lothian and Hee Haw to produce further information films on fertility preservation and hormones, to be completed by March 2021

31/03/21 David Parker

Service users have a comprehensive resource to refer to and are fully informed of the implications of their treatment choices

2020/21-07

Network to continue to engage with the community across Scotland through a variety of media by the end of March 2021

31/03/21 Steering Group

Service users understand the role of the network and inform its priorities in future

2020/21-08

Network to support commissioning colleagues in their taking forward bids for designation for C&YP service and surgical services in Scotland, as required


Commissioning colleagues will have access to those with suitable expertise to ensure bids are as well prepared as possible

2020/21-09

Steering Group will meet four times within the twelvemonth period, with subgroups convened as required


Delivery of the NGICNS network workplan to ensure improvement in patient care


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2020/21-10

Steering Group publicise to all gender clinicians in Scotland the next intake for the gender diploma


Gender clinicians will be aware of an accredited training course that may assist their CPD


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Appendix 1: Steering Group Membership Alphabetical list of Steering Group members as of 31 March of reporting year, stating their designation and where applicable, the Health Board/organisation they represent.

NHS Tayside Linda Graham Chair; Clinical Lead for Mental Health and Learning Disabilities

NHS Lothian David Parker Lead Clinician; Senior Clinical Nurse Specialist

University of Edinburgh Richard Anderson

Head of Section, Obstetrics and Gynaecology (University of Edinburgh

LGBT Youth Scotland Nicola Booth Head of Youth Work

NHS Fife Susan Brechin Consultant in Sexual Health

NHS Lothian Daniel Clutterbuck Consultant Genito-Urinary Medicine

NHS Lothian Alison Craig Clinical Nurse Manager

LGBT Youth Scotland Paul Daly

Senior Practitioner, Policy and Research, LGBT Youth

Scottish Government Sarah Duncan Legal Dept.

TransparenTsees and Mermaids Allison Ewing Parent Group Rep. NHS National Services Scotland Aileen Ferguson Programme Manager

NHS Greater Glasgow & Clyde David Gerber Clinical Director

NHS Highlands Fiona Gibson Speciality Doctor

NHS Grampian Steven Hay Consultant Psychiatrist

NHS Grampian Amber Keenan Principal Clinical Psychologist

NHS Lothian Sarah Kennedy Lead Clinician, Chalmers Gender Identity Clinic

NHS Lothian Yvonne Kerr Programme Manager, Sexual Health

RCGP Anna Lamont

GP, NHS Forth Valley, Associate Medical Director NHS 24

NHS National Services Scotland Claire Lawrie Programme Manager


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NHS National Services Scotland Roseanne McDonald

Programme Associate Director Nursing & Quality

LGBT Health and Wellbeing Katrina Mitchell

Development Worker (Trans Support Programme)

Scottish Transgender Alliance James Morton

Scottish Transgender Alliance Manager

National Services Scotland Hugh O'Pray Data Manager

NHS Grampian Victoria Ross Trainee Clinical Psychologist NHS National Services Scotland Luke Rush Programme Support Officer

NHS Greater Glasgow & Clyde Jennifer Schofield

Adult Services Manager – Sexual Health

Stonewall Scotland Megan Snedden

Campaigns, Policy and Research Officer

NHS National Services Scotland Alexandra Speirs Senior Programme Manager

Scottish Government Simon Stockwell

Head of Family & Property Law Justice

NHS Greater Glasgow & Clyde Gordon Wilkinson

Lead Clinician, Gender Identity Clinic, Young People's Service

National Union of Students Scotland Ethan Wilson NUS Scotland LGBT+ Officer NHS National Services Scotland Louise Wilson Senior Programme Manager


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Appendix 2: Finance

Note: The £3,000 is a contribution towards an NHS Lothian-led information film on fertility preservation and hormones


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Appendix 3: Network Progress against Review Priorities

Objective Number

Strategic Objective Description of progress towards meeting objective as at 31/10/2019


Review recommendation 1

By March 2019, NGICNS will liaise with NHS planners & service managers to ensure equitable services

The network will invite a regional planning representative onto the Steering Group

This issue was raised by the lead clinician at the management meeting in NHS Lothian

The previous NSD Medical Director sent a SBAR to Regional Planners

Links were made with Karen Grieve’s team to take this forward and a letter was sent to the Directors of Planning

See also 2019/20-02 and 2019/20-09

NHS Scotland planners are aware of the need for equitable services and accordingly, NGICNS supports them in their planning

(B)


Complete a mapping exercise of broader gender services to identify additional areas for improvement to be included in future workplans

The report is complete and available on the NGICNS website.

See also 2019/20-09

Clear baseline data regarding all GRP services, to be used to support Boards in providing a more equitable service

(B)


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Network to develop QPIs on;

Access to service (referral to

assessment) – suggested

maximum of RTT equivalent

(currently 18 weeks)

Referral to surgery (waiting times)

Referral to Hormones

Referral to Hair removal

Information for people on waiting

list including current waiting time

to ensure there are standards against which services can be measured, by March 2019

This has been included in the five year workplan, the first step is to collect baseline data in these areas, which is work that we are taking to the NaSH managed via Claire Lawrie

QPIs will provide measurable standards which can be audited against to provide baseline and improvement data, to be used to support Boards in providing a more equitable service

(A)


The network will build on its existing good engagement with primary care

See current workplan 2019/20-14 Primary Care will have access to up to date and high quality education about the needs of the gender community

(G)


NGICNS will work to increase awareness of services outwith the central belt via service user engagement sessions and other dialogues

See current workplan 2019/20-12 Service users will have increased awareness of the work of the network and a vehicle to feedback their experiences and concerns, to improve patient care

(B)


The network should review results of service mapping and assist NHS Boards where possible to develop local psychotherapy services for all people using GICs

See current workplan Clear baseline data regarding the availability of psychotherapy services, to be used to support Boards in providing a more equitable service

(G)


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By the end of March 2019, NGICNS to take forward the recommendations from the ScotPHN needs assessment report, with initial results presented to the May 2018 SGp meeting.

These actions are noted below Data will be available on the future needs of the gender community, which can be considered by the Steering Group, and used to inform future work of the network


By the end of March 2019, NGICNS will revise its existing designation objectives to reflect the scope and authority of NMCNs

Programme Manager to update SA as per guidance from Programme Associate Director

Clear realistic deliverables will be set out in governance documents

(B)


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Appendix 4: Network Progress against ScotPHN Priorities

Objective Number

Strategic Objective (These objectives are recommendations made in the ScotPHN 2017 report, included for governance purposes only)

Linked Dimensions of Quality



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1 1. Consider alternative models of care for gender identity services to support the development of multidisciplinary, person-centred approaches which reduce variation, including the potential for:

a. Additional local provision of both specialist

and support services within the NHS

b. Additional involvement of primary care services

c. Additional involvement of community and

voluntary sector in service provision d. Centralised commissioning of additional

services e.g. hair removal.

Re. ‘a’, a SBAR has been drafted for Dr Winter to take to Regional Planners – submitted to Steering Group 29/1/2018, highlighting vulnerability of services. An application for national designation for the National Young People’s Gender Service is being progressed. An application for local surgical services has also been developed, see also 2018/20-03.

For adult services there is a critical shortage of clinicians trained to undertake initial assessments for non surgical interventions. The network is supporting the urgent provision of a competency framework for this intervention with a view to improving accessibility. It notes that boards hosting GICs will need to ensure appropriate funding to expand the GIC workforce.

Re. ‘b’, meetings have taken place and agreement has been reached to draft a GP protocol for care of gender patients in Primary Care. Work is progressing on this protocol. Colleagues have been meeting regularly with GP representatives at a local level at one GIC in order to understand the structure and content of a formal shared care agreement.

Re. ‘c’, all protocols and developments will be signed off in partnership, and there is input from LGBTYouth, LGBTHealth, STA, Transparentsees, the NUS and Stonewall Scotland on the Steering Group.

Re. ‘d’, it has been confirmed that commissioning of hair removal services is not within the national remit, however, NGICNS has developed guidance for Boards on this topic.


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2 2. Ensure gender identity services are adaptable to changes in the trans population presenting to GICs e.g. increasing numbers of non-binary and gender diverse people, those exploring their gender identity, and younger patients, for example through: a. Ensuring equality of access to services for non-binary individuals b. Offering non-assessment focused services within GICs e.g. separate exploratory space to discuss gender identity and treatment goals c. Resourcing of third sector organisations to work with those in the early stages of questioning or exploring their gender identity d. Access to email/online support.

The network has undertaken to ensure the review of the gender reassignment protocol remains a priority when WPATH guidance V8 is available, and this will involve input from stakeholder groups. The network is also supporting a bid for designation for the C&YP service.

3 3. Increase the support which is available to individuals on waiting lists for GICs, through greater partnership work including signposting to voluntary sector and community support, increased communication about likely waiting time, provision of interim NHS services where possible, and advice on potential risks of self-medication

Waiting times for chest reconstruction surgery are now published and updated on the NGICNS website.

Additional representation from Boards without GICs has been added to the Steering Group.

Service mapping completed.

The adult leaflet is progressing, along with other NGICNS Comms and engagement work, detailed elsewhere in the report.


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5 5. Take steps to address geographical inequalities in accessing services through: a. Provision of alternatives to travel e.g. telemedicine, satellite clinics b. Increased communication of GICs with local NHS boards about patients attending to facilitate local assistance where possible e.g. phlebotomy, counselling, endocrine support c. Consideration of establishing additional GICs or other dedicated services e.g. as in NHS Tayside ‘hub and spokes’ model d. Increase provision of community support to ensure this is more widely available to trans people across Scotland.

Service mapping completed,

Discussion regarding outreach clinics continues, and a proposal to include outreach clinics in the C&YP service was included in the bid for specialist service designation to NSD. This bid with reach its next stage in 2020/21.

GICs are exploring options for remote consultations including using NearMe.

8 8. Strengthen collaboration to ensure services meet the needs of the trans population, including wider healthcare and support needs, by involving trans people, third sector organisations and community

See 2019/20-02 and 2019/20-12.


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9 9. Continue workforce development efforts to expand specialist workforce and support workforce including: a. Development of further training programs for specialist, generalist primary care and mental health staff b. Development of links with other sectors to enhance multi-disciplinary working and share resources e.g. education, social care.

It was agreed that workforce development was less of a network issue and more of a GIC issue, however, there has been a great deal of collaborative work on the bids for local Board funding for the GICs, with additional funds secured for the Grampian and Highland services. Job descriptions are being shared across Boards in a bid to streamline job roles and cut down on duplicated work.

A virtual MDT has been set up.

Gender clinicians in Scotland have been informed by the network of a new Postgraduate Certificate / Diploma course in gender medicine being run by the University of London, attendance at which could lead to a more consistent training pathway for GIC staff. It recognises however that this qualification may not be suitable for all GIC staff and is supporting the creation of a competency framework for non surgical interventions to improve choice and accessibility for the GIC workforce.

The network has been making links with Sexual Health and other specialties in preparation for the move to implement ICD11, which may lead to a closer alignment of gender services with sexual health and concurs with the position of the World Health Organisation that gender incongruence is not a mental health condition.

10 Develop national standards for what is required to be established as a Gender Identity Clinic.

This was not viewed as a high priority compared to other more pressing areas, and it could be incorporated into the work of revising the GRP. The group noted the need for flexibility in approach.

Core competencies for staff are, however, being developed.

Work took place to ensure all GIC clinicians are on the gender recognition panel.


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11 11. Increase data gathering on the trans population and from GICs to assist with monitoring inequalities and for research purposes. From GICs, this should include as minimum dataset components:

a. Number of referrals

b. Age at referral

c. Gender identity

d. Ethnicity

e. Health board of residence

f. Waiting times

g. Treatments undergone

h. Outcome of treatment

i. Service user satisfaction

Work is progressing on gathering the expanded dataset via the data sub-group. Amendments to the NASH system will be taken to the NASH Manager by Claire Lawrie.


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Appendix 5: Data

Note: This table shows the referrals made by GICs in Scotland for ‘upper’ and ‘lower’ gender reassignment surgery. Surgery was carried out in London, Manchester and Brighton under contract with NHS England. It is likely that the 2019/20 figures are artificially low because there have been ongoing changes to providers commissioned in NHS England which in turn has led to some surgery referrals being delayed


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Note: This table shows the actual waiting times at GICs. From January 2019 each centre provided data in response to the question ‘As at the last day of the quarter, patients are being seen for first appointment who were referred in mm/yy’. This was then converted into a number of months for reporting purposes. Only the historic

data from the Lothian and Highland centres is compatible with the new waiting time definition. Note that the 2019/20 Q4 data is not yet available.


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Note: This table shows the number of patients waiting for a first appointment at a GIC by quarter. Note that the 2019/20 Q4 data is not yet available.


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Note: This table shows the patients seen by quarter, as split by service. Note that the 2019/20 Q4 data is not yet available.


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Note: This table shows the new and returning patients seen by quarter. Note that the 2019/20 Q4 data is not yet available. This is a recent addition to the data collected, as it was felt useful to differentiate between new and return appointments to enable a comparison between dem and (i.e. the waiting list numbers) and capacity (the number of new patients seen). This was not possible prior to Q4 2018/19 because data was collected only on the total number of patients seen.

Documents

NMCN Annual Report€¦ · Development of a Competency Framework (objective 2019/20-08) has been progressing through a sub-group set up and led by Dr Ben Hall (Scottish Clinical Leadership