The Gender Identity Development Services at Tavistock and Portman NHS Foundation Trust’s London and Leeds clinics have been rated inadequate by The Care Commission and told to improve their services and waiting times significantly.
Inspectors carried out an announced, focused inspection at the trust in October and November due to concerns raised by healthcare professionals and the Children’s Commissioner for England relating to clinical practice, safeguarding procedures, and assessments of capacity and consent to treatment.
The Gender Identity Development Service is a national specialist service and is the only service available in England.
Kevin Cleary, CQC's Deputy Chief Inspector of Hospitals, said: “When inspectors visited the Tavistock and Portman NHS Foundation Trust GIDS in October, we identified significant concerns and took enforcement action by imposing conditions on the registration of the trust.
“We fed back our concerns to the trust and also to NHS England and NHS Improvement. We were extremely clear that there were improvements needed in providing person centred care, capacity and consent, safe care and treatment, and governance. In addition vulnerable, young people were not having their needs met as they were waiting too long for treatment. The action we took was one way of ensuring the trust was tackling these issues in a way which allowed other healthcare partners to support if necessary.
“The trust leadership team knows exactly what improvements are needed and we will continue to monitor the trust extremely closely during this time. We will return to inspect services and expect to see these improvements in place and be thoroughly embedded,” he added.
The Tavistock and Portman NHS Foundation Trust only provides outpatient mental health services. All other medical treatment needed is provided by other healthcare providers referred to by the Tavistock and Portman NHS Foundation Trust.
Medical treatment involves the prescribing of medicines that pause the physical changes of puberty and hormones that alter characteristics of gender and is provided by the endocrinology departments at University College Hospital London and Leeds General Infirmary. The CQC inspected and published reports on these services at the same time as the inspection and publication of gender identity services.
- More than 4,600 young people on the waiting list with some young people having waited over two years for their first appointment.
- Staff did not always manage risk well. Many of the young people waiting for or receiving a service were vulnerable and at risk of self-harm. The size of the waiting list meant that staff were unable to proactively manage the risks to patients waiting for a first appointment.
- For those young people receiving a service, individual assessments were not always in place with plans for how to manage risks.
- The number of patients on staff caseloads resulted in high caseloads which placed pressure on staff.
- Staff had not consistently recorded the competency, capacity and consent of patients referred for medical treatment before January 2020. However, since this date these decisions had been recorded.
- Staff did not develop all-inclusive care plans for young people. Records of clinical sessions did not include any structured plans for care or further action.
- Staff did not fully record the reasons for their clinical decisions in case notes.
- There were significant variations in the clinical approach of professionals in the team and it was not possible to clearly understand from the records why these decisions had been made.
- Staff did not always feel respected, supported and valued with some saying they felt unable to raise concerns without fear of retribution.
- The service was not consistently well-led. Whilst areas for improvement had been identified and some areas improved, the improvements had not been implemented fully and consistently.
However, the report highlighted that staff treated young people with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. Patients and families and carers were actively involved in care decisions. Feedback from young people and families currently being seen at the service was overwhelmingly positive in terms of the care and support staff had provided.
Staff referred young people to other providers for medical treatments that was in line with good practice. Staff received training, supervision and appraisal and the service treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with staff.
Following the inspection, CQC used its enforcement powers to impose conditions on the trust’s registration. The conditions applied to the trust’s registration are: The trust must provide a written report each month setting out:
- The actions taken to ensure the systems in place for the management and reduction in the GIDs patient waiting list are effective.
- The results of any monitoring of the system undertaken by the trust.
- A report of the number of patients on the waiting list, including monthly figures of new referrals awaiting an assessment, those assessed and receiving treatments, and patients discharged or referred onto another service.
At this inspection, the GIDS were rated Inadequate for being well-led and responsive to patient’s needs, Requires Improvement for being safe and effective, and Good for being caring. Overall the service is now rated as Inadequate. At the previous inspection in 2016, the CQC rated the Gender Identity Development Service as Good.
A spokesperson for The Tavistock and Portman NHS Foundation Trust said: “We take the CQC’s report very seriously and would like to say sorry to patients for the length of time they are waiting to be seen, which was a critical factor in arriving at this rating. We know the difficulty this wait is causing them and their families and we agree with the CQC that the growth in referrals has exceeded the capacity of the service.
“We very much accept the need for improvements in our assessments, systems and processes. In addition, we have submitted our plan to improve the management of our waiting list to the CQC and are working with our commissioners, NHS England, and others to improve access to the service. We are determined to get this right for children and young people and will be agreeing a full action plan with the CQC to address further concerns.
“We are already finalising plans to bring in senior clinical and operational expertise from outside the service to help us implement the necessary changes and consider how we can improve on current processes and practice – including how we standardise our assessment process.
“We will continue to support Dr Hilary Cass who has been commissioned by NHS England to make recommendations on the care provided to children and young people questioning their gender identity or experiencing gender incongruence.
“Above all, we remain focused on providing a high quality service to children and young people in our care and supporting our staff who, despite the challenging context they have been working in, have been praised by the CQC for their understanding, compassion and kindness. Patient feedback was reported as overwhelmingly positive and we will involve both patient and staff as we build on these strengths.
“The GIDS endocrinology services at UCLH and Leeds Children's Hospital, which prescribe any medication to young people, were also reviewed. The findings at both were positive, the CQC noting that they “supported young people and their families to make informed decisions” and “had a good understanding of Gillick Competence and applied this proportionately when obtaining consent from young people”.
“The Tavistock and Portman NHS Foundation Trust is committed to providing high quality care to patients and its overall rating remains ‘good’,” the spokesperson concluded.
The NHS will undertake an independent review into gender identity services for children and young people. The review will present recommendations to NHS England and Improvement’s Quality and Innovation Committee. The Gender Identity Development Service is a national specialist service and is the only service available in England.
Read the report on Gender identity services, Tavistock and Portman NHS Foundation Trust