If you’ve read my articles up to now you may have noticed that while I have dug into the origin of the National Gender Service’s (NGS) Model of Care (MoC), I have included only two brief screenshots of its content. You may be wondering will I ever get to properly discussing contents of the MoC?
Well today is your lucky day! This will be my first article looking at the MoC itself, starting naturally from the first paragraph.
As you may have gathered, as is often the case with the NGS, things which should be simple turn out to be far more perplexing than you’d expect. This is no exception as the first hurdle I ran into is what is the MoC? I don’t mean what is the actual practice within the NGS, which is of course different again, but what is the official MoC on paper?
Five! Three, sir!
I’ve been researching Irish trans healthcare for just over a year, and thus far have encountered five distinct documents which appear to be the Model of Care of the National Gender Service. No two are perfectly identical, however a meticulous word-by-word comparison of the 4406-4566 word documents finds that two pairs of documents have identical wording, reducing this down to three sets of MoCs.
I will refer to these as the 2016 MoC, 2018 MoC, and 2019 MoC.
The 2016 MoC can be found as Appendix Two of the 2017 Quality Improvement Division Model of Care, which mentions that it was developed during 2016.
The 2016 MoC was also included as an attachment in the email to the CEO of TENI on 9 October 2018 with the following explanatory text:
For context the business case referenced is for the 2017/2018 estimates process, and this predated the creation of the Steering Group that went on to establish the NGS.
So given that the meeting to approve the MoC was on 6 September 2018 and that this email to TENI was sent a month later on 9 October 2018, one would presume that this was that very MoC.
Sadly that does not appear to be the case. It would seem that either the author of the letter wasn’t aware that the MoC had changed from this version and thought that it was an accurate representation of the MoC, or knowingly sent on a MoC that was out of date.
So what was approved?
As part of an FoI I was informed that “In my opinion, as they were shared and in so far as I could determine by speaking with participants in the meetings, that these documents were the final approved documents by the Steering Group.” That approval would have been on 6 September 2018, and is for this version:
So this looks like it could be the approved final version, you can see if you compare the screenshots there’s relatively minor changes to the first paragraph such as no longer stating that it’s a proposal. While administrative cleanups like that aren’t a big deal, there are more significant changes from the 2016 MoC.
One of those changes is adding references to a paper published on 16 August 2018, so this MoC version must have been written after that. Notably this means that some of the changes happened after the meeting with Dr. Crowley on 9 July 2018, wherein it was subsequently claimed in the 6 September 2018 minutes of the Steering Group that established the NGS that:
This indicates that any Model of Care discussed with Dr. Crowley at that meeting cannot have been the final version.
One sign that this is the final version is that, among the more minor changes, this is the only MoC version where staffing numbers for adult services:
match with what was granted by the HSE per sources including the Project Initiation Document of the Steering Group:
I presume the 0.6 Administrators is a typo, and it should be 0.5 as it is elsewhere.
There is another.
As I previously covered a FoI to the Department of Health (DoH) returned a MoC that was dated the 22 February 2019. As you may recall the NGS claimed in their 28 January 2021 letter to the CEO of the HSE that the NGS MoC had been accepted by the DoH on 9 February 2019, but which the DoH said they had no part in.
This 2019 MoC is different to the 2018 MoC. Which is to say that the DoH not only didn’t accept the 2018 MoC, but they didn’t even get a copy of the 2018 MoC to accept during February 2018. The changes between the 2019 MoC and 2018 MoC are smaller than between 2016 MoC and 2018 MoC, but still go beyond administrative cleanups.
Next, I’d like to consider the lineage of these three documents. If you look at the above screenshots it’s fairly obvious that the 2016 MoC is the oldest version, given that only it uses “Proposal for” in the title. However only the 2018 MoC uses the word “person” rather than “patients” so it is the newest version. There are more cases like these within the MoCs, which is to say that the order in which these were written is 2016 MoC -> 2019 MoC -> 2018 MoC.
As an aside I do find it interesting that the “patients” to “persons” change depathologises being trans, while at the same time the offensive term “transgendered” wasn’t corrected to “transgender” thus denying trans identities.
Fixing the Timeline
There’s two things that appear fairly certain here. Firstly, on 9 October 2018 TENI was told the NGS had been created and given a MoC which was not the final MoC of the NGS. Secondly, during the 9 July 2018 meeting with Dr. Crowley where Dr. Crowley supposedly accepted the NGS’s MoC, the MoC discussed couldn’t have been the final version.
In relation to the 2019 MoC sent to the Department of Health at least one of the following appears to be true, if the 2018 MoC is indeed final. The DoH was sent an outdated version of the NGS’s MoC in February 2019, and/or the NGS’s MoC was changed by someone after it was approved in September 2018.
In the next article, the second paragraph of the MoC may make an appearance.
Jessica Black (she/it) wishes that the phrase “not being bound by the restrictions of linear time” could go back to being a joke.