How the National Gender Service’s Model of Care came to be

How the National Gender Service’s Model of Care came to be

What exactly is the Model of Care (MoC) that the National Gender Service at St Columcille’s Hospital in Loughlinstown follows? One would hope that it was in line with the proposal published in January 2017, spearheaded by Dr. Philip Crowley of the HSE’s Quality Improvement Division (QID) and generally following the international best practice WPATH v7 Standard of Care guidelines. This was based on consultations with both professional bodies such as the Psychological Society of Ireland and The Irish Endocrine Society, and patient organisations such as TENI and BeLonG To. Is it the MoC used though?

Documenting inadequate care

In July 2019 an unknown individual sent in a Freedom of Information (FoI) request asking for any documents around the MoC for transgender people in operation in the HSE, and a proposed model of care by the HSE’s QID. In response to this FoI request all that came back was a single 73 page document the entitled “Transgender Health: Proposed Service Development Model for Transgender Children, Adolescents and Adults”, dated January 2017 with no context. The document is from the QID and contains a main proposed model of care, plus two other proposals in appendices. Given the wording of the FoI request one would presume that indeed the main proposal in this document is the model of care in use by the National Gender Service (NGS).

The true story is more complex. To understand it we need to consider documents from 2017 to 2021 which are spread across four FoI requests.

To start with is a letter from 28 January 2021 on behalf of the NGS Clinical Governance Committee to Paul Reid, the CEO of the HSE. This letter expresses grave concerns with the Final Report of the Steering Committee on the Development of HSE Transgender Identity Services, dated February 2020 but only published in December 2020. There’s a lot to unpack in this letter. But I’m going to focus on the MoC section in this article. Let’s start with the first paragraph:

So it would appear that the NGS is not following the MoC that was published January 2017 and instead a different steering group established a different MoC independent of this.

How did this Ireland East Hospital Group (IEHG) Steering Group come to be? The letter says:

Naturally, of course, I put in a FoI request asking for all records around this steering group, which the HSE were kind enough to provide.

However, and oddly, none of the FoI records mention this while they do mention parliamentary questions (in the sense of wanting to be able to answer them). And there’s also nothing in them about them being the reason for this steering group. In fact a letter to TENI’s CEO on October 9th 2018 from this steering group says:

The first minutes of the steering group also mention this business case, but nothing about parliamentary questions or the Department of Health. So the claim that the Department of Health requested this steering group seems a bit dubious. The letter also claims that the Department of Health subsequently accepted this different MoC:

I sent in a FoI to the Department of Health about this acceptance on 6 February, 2019, which they disagree with:

The Department of Health did release a copy of the MoC dated from the 22nd of that month to me under FoI, but nothing from the 6th. At most, the Department of Health received a copy but did not accept it as the letter claims. The letter goes on to state:

So it sounds like the QID MoC was formally rejected by this steering group prior to 9 July 2018. The minutes of 16 June 2018 mention the QID MoC and reaching out to Dr. Philip Crowley, but no formal rejection:

The minutes of 31 May 2018 also mention setting up a meeting with Dr. Philip Crowley, but again no formal rejection:

The next steering group meeting is on 28 June 2018 and only mentions that the meeting with Dr. Crowley will be on 9 July 2018.

The next steering group meeting took place on 6 September 2018, after the meeting with Dr. Crowley. So it would appear that it was not in fact formally rejected as that’s not mentioned in the minutes, thus Dr. Crowley could not have been informed of it. What the 6 September 2018 minutes do say is:

This doesn’t sound like informing Dr Crowley of a formal rejection of a MoC that he had worked on. Several assertions of the letter of 28 January 2021 to the CEO of the HSE are not supported by their own records or those of the Department of Health. It would appear as though this steering group did not formally reject the 2017 MoC before their meeting with Dr Crowley on 9 July 2019, the group was not established at the behest of the Department of Health, and produced a MoC which the Department of Health had no part in accepting.

The minutes of the 6 September meeting include the steering group accepting a MoC for the National Gender Service presented by Dr. Paul Moran:

So, there you have it. The NGS MoC was approved on September 6th 2018 by a steering group within the IEHG separately from the 2017 QID MoC returned by the original FoI. It is not the MoC that was developed in cooperation with professional bodies and patient organisations, but instead has a completely separate history.

Jessica Black (she/it) inhales FoIs so you don’t have to.

Featured image via – Nick Youngson

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