Is the National Gender Service designed to be efficient?

My previous two articles revealed that there are three versions of the National Gender Service’s (NGS) Model of Care (MoC), with the final version not being the one sent to the the Department of Health. Over time references to the Transgender Equality Network of Ireland (TENI) were removed and TENI was sent an outdated version of the MoC that still mentioned them while the only modern addition to the references was to a highly controversial paper that is referenced by transphobes to this day. In addition, while 2018 MoC covers 17- and 18-year-olds within the NGS, only months afterwards they were left in the lurch when the service was summarily made over 18s only.

These are not the only significant changes across the version of the MoC, which in all lead me to the conjecture that the NGS was purposefully designed to be as inefficient as could be gotten away with. It’d be difficult to justify providing effectively no healthcare. However, you could squander the resources the HSE made available.

One to Four

In the 2016 MoC, the initial assessment is with one medical professional for 90 minutes:

In the 2018 MoC, this has jumped to two assessments with two medical professionals, each for at least 90 minutes:

That’s four times as many staff resources used by simply changing a document! There’s no obvious explanation for this change anywhere, either in the MoCs, meeting notes, or other documents.

However, we can look at changes made to the MoC at the same time. Aside from the two references discussed in my previous article, a new “International Clinical Guidelines” section was added which would seem the logical place to find a justification for such a major change. 

International Clinical Guidelines

The first international guideline is the 2017 Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline. The Endocrine Society Guidelines are pointed to by WPATH v7 and reference, and I have personally used these guidelines as part of my own transition. They’re a bit outdated in 2022. But in 2018 they’d have been a good representation of the medical consensus on trans endocrinological matters.

I have gone through all 35 pages of the guideline and can find nothing to support this change. It has a general set of criteria that an assessment for adults should meet but nothing about how many or what specific type of medical professionals should be involved, nor for how long.

The second international guideline is really a UK national guideline, and is entitled Good practice guidelines for the assessment and treatment of adults with gender dysphoria and was published by the Royal College of Psychiatrists in 2013. This is a document I wasn’t previously familiar with. It is based on WPATH v7 and is obviously of its time in terms of gatekeeping. Yet, in that context, is quite patient focused. If the NGS had taken this document as their MoC, we’d be in a much better place.

I went through all 61 pages of the guideline, and did find something relevant on page 26:

So the International Clinical Guidelines added to the MoC at the same time as to the quadrupling of assessment staffing need don’t support this change. In fact they support the exact opposite, the original one medical professional approach!

The NHS Report

In a previous article I looked at a 2015 NHS report which the NGS states provides a clear view as to how Gender Clinics in the UK operate and use it as a justification for the NGS following this instead of WPATH. This is of course turned out to be far from the truth. For example, they actually operate in six different ways all of which follow WPATH. But there are other parts of the report that are of interest here.

As you may recall, the context of the NHS report is to help the clinics be more efficient, avoid potential pitfalls, and improve waiting list times. Chapter 10 does some theoretical modelling. The first model is what happens if you combine two separate appointments with different staff into one:

Put another way, having to get two staff into the same room at the same time makes scheduling harder. In this case patient throughput is the same, but takes 46% longer for patients.

So, requiring two staff to do each assessment not only halves throughput but is also slower for the patients once they get to the front of the waiting list.

The second model is what happens if you keep patients within the system while they wait for surgery. This is about therapy provided during that time. But the same logic would apply to other appointments such as seeing the endocrinologist every six months as the NGS requires.

As you’d expect, someone might take their time to decide if surgery is for them and then have to wait to actually get that surgery, all the while using up two endocrinologist slots a year even if they’ve reached their final HRT dosage and are stable. Which is exactly what the NGS MoC does:

It is interesting to note that the Royal College of Psychiatrists 2013 guidelines mention that prescribing could be handled primarily by GPs rather than endocrinologists: 

And that patients could be discharged back to GPs before any potential surgery was complete:

The third and final model in the NHS report is of the staffing requirements in the face of increasing growth in patients. And that particular model notes that growth of just 25% needs 50% more staff to keep waiting times acceptable:

All versions of the MoC mention an ongoing year-on-year increase in referrals:

The 2018/2019 MoCs add some useful referral statistics:

So at a minimum you’d want the NGS to be able to handle 209 new patients a year and preferably with a lot of extra capacity to cover the expected increases in future.

In that light, making the assessment process take four times the staff seems like a questionable choice, particularly given that 2021 news articles indicate that the NGS can handle only 150 new patients a year.

But wait, there’s more!

Today the process takes even more staff than even the final 2018 MoC requires, as stated on the NGS website

So an extra 90 minutes with two staff was added in at some point, meaning we’re now at six times the staffing requirements compared to what the initial 2016 MoC would have required.

Another demand on the time of the NGS are Multi-Disciplinary Team (MDT) reviews of the assessments, with at least three required for each patient:

This is the effectively the same effort in the NGS MoC as for the NHS Newcastle which, as previously noted, was considered “Overly complex MoC multiple triaging” by those behind the NGS. So, the NGS going with an approach they themselves called overly complex is certainly a choice.

The final wrinkle in relation to NGS assessments is that for a significant chunk of people two assessments isn’t enough, at least according to the NGS thanks to the results of a successful a 2021 Freedom of Information (FoI) request:

This is astounding, that something that previously was thought to be generally possible in 90 minutes of a medical professional’s time in the 2016 MoC now can’t be done in 540 minutes in over a third of cases.

It’s not only the assessment of the NGS that seems excessive and wasteful. If you want surgery you must use endocrinologist slots even if you have been stable on HRT for years:

This is in addition to being made go through the whole NGS assessment process even if you’ve already been assessed elsewhere, which Royal College of Psychiatrists 2013 guidelines indicate is not in line with the rights of patients:

Veneer of Respectability

In all, the above paints a picture. On one hand the creators of the NGS MoC seem to be happy to cherry pick parts of documents that they rely on that’d make trans healthcare harder to access, take longer, and more invasive for the patient. For example, the addition of a specific mention of psychosexual history as seen near the start of this article is supported by the Royal College of Psychiatrists 2013 guidelines:

On the other hand, the MoC authors seem to be equally happy to ignore the parts of the documents that would make life easier for trans people seeking healthcare. In addition to the various examples above, the 2017 Endocrine Society Guidelines mention getting information about psychosexual development for children, but not for adults.

I have a suspicion that some of these references were added not because they are what underpins the NGS MoC, but instead to make the document look more considered and respectable. Particularly given how little of the overall text of the MoC changed when the international clinical guidelines were added. Maybe it was thought that no one would actually go and check what the international clinical guidelines and other documents the MoC claim as a basis actually say, let alone do a word-by-word comparison of the different MoC versions.

As a final thought the NHS report points out some practices which will lead to increased waiting times. And we know these were read as they are mentioned in Gender Clinic Operational Model of Care September 2018 (GCOMoC) that was presented with the MoC:

The NGS implements all of these practices, and I’m not seeing the supposed benefits to the patient. It’s almost as if the NHS report was treated not as a warning about how to avoid lengthy waiting lists, but as an instruction manual.

Where NGS practices have varied from the MoC since, it has been to the detriment of trans people such as by leaving 16- and 17-year-olds in the lurch, excluding patient advocacy groups, and making assessments take even longer.

All while waiting lists have been growing.

Is Jessica Black (she/it) going to lose to Betteridge?

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