“Significant concerns” have been raised by inspectors of the UK’s leading gender identity service, to which more than 180 Irish children have been referred since 2015.
The Care Quality Commission (CQC), England’s equivalent to the Health Information and Qualitative Authority (Hiqa), rated the Gender Identity Development Service “inadequate” following an announced inspection in late 2020.
Investigators highlighted long waiting lists and insufficient record-keeping, prompting the CQC to take immediate enforcement action against the Tavistock and Portman NHS Foundation Trust which runs the service. As part of its enforcement action, the CQC is now demanding monthly updates on the status of the waiting list and actions being taken to reduce its length.
In the two-year period to April 2020, 85 Irish children and teenagers were referred to the service, according to its website. The psychological services at Children’s Health Ireland (CHI) at Crumlin are provided by the Tavistock clinic and funded by the Treatment Abroad Scheme. The scheme allows consultants to refer patients to have treatment elsewhere in the EU, the European Economic Area or Switzerland if the procedure is not available in the Republic within the time necessary.
A Department of Health spokesman said under the EU-UK Trade and Co-operation Agreement signed last month, people resident in Ireland would continue to be eligible to access planned healthcare in the UK after Brexit as they would do under the Treatment Abroad Scheme.
The HSE published a report in December recommending a move away from psychological support provided by the Tavistock to a service provided and delivered by the Irish health system.
CHI said on Thursday it “currently had no active patients” under the primary care of the British service.
The CQC report, published on Wednesday, noted long waiting lists for the gender identity service, with some young people distressed about their gender identity waiting more than two years for a first appointment. Many of those referred to the service are described as “vulnerable and at risk of self-harm”, and inspectors felt the risk to those not yet seen was not being proactively managed.
For those receiving treatment at the service, individual risk assessments were not always in place. Record-keeping at the service was also criticised, with inspectors noting that “staff had not consistently recorded the competency, capacity and consent of patients referred for medical treatment before January 2020”. This had changed in the meantime, but an audit of 10 records for young people referred for hormone blockers in the spring of 2020 found only three contained a completed consent form and checklist for referral.
Also noted were “significant variations in the clinical approach of professionals in the team”, making it unclear why some clinical decisions were made. Assessments of patients were “completely unstructured”, with some young people receiving two to three sessions and others attending more than 50. There was no explanation for such a high variation and no standard questions for staff to explore with patients.
“None of the records included a clear statement of what the service was assessing,” inspectors observed.
Furthermore, there was “insufficient evidence” that staff considered the specific needs of young people, such as those with autistic spectrum disorders.
“The service did not record how many patients had a diagnosis, or suspected diagnosis, of an autistic spectrum disorder,” the report states. Of a sample of 22 records, more than half referred to autistic spectrum disorder or attention deficit hyperactivity disorder (ADHD). However, consideration was not given to the relationship between autistic spectrum disorder and gender dysphoria.
A 2016 CQC inspection rated the service “good” overall but a number of concerns were raised by healthcare professionals and the Children’s Commissioner for England in the interim.
The report published on Wednesday found that staff did not always feel respected, supported and valued, with some feeling “unable to raise concerns without fear of retribution”. The service was “not consistently well led”, and governance processes “did not operate effectively to ensure that the needs of patients were met in a safe, structured and systematic manner”.
On a more positive note, inspectors observed that staff treated young people with compassion and respected their privacy and dignity. Parents and guardians were “actively involved” in care decisions and feedback from young people and their families was “overwhelmingly positive”. The report also noted that staff referred young people to other providers for medical treatments that were consistent with good practice.
When contacted by The Irish Times, CHI at Crumlin noted that the Tavistock had suspended new referrals for patients under the age of 16 following a High Court ruling in England last December.
The court ruled that children considering gender reassignment were unlikely to be able to give informed consent to receive puberty-blocking treatment.
A spokeswoman for CHI said it ceased referring patients to the Tavistock following the ruling. It said it “currently had no active patients” under the primary care of the British service and no patients are awaiting referral. These patients are now “under the care of services in CHI at Crumlin”, she said.