UK

NHS gender clinic quietly changes discharge policy ‘putting most vulnerable patients at risk’

Lily Wakefield February 15, 2022
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An NHS banner seen during a Pride in London parade.

An NHS banner seen during a Pride in London parade. (Getty)

A policy of discharging patients for missing, in some cases, just one appointment at London’s only NHS Gender Identity Clinic is putting the most vulnerable at risk, a whistleblower has said.

The adult Gender Identity Clinic (GIC) in North London, under the Tavistock and Portman NHS Foundation Trust, one of just seven in all of England, introduced the policy with immediate effect at the end of January.

Under its previous rules, after one missed appointment, a GIC patient would be contacted to arrange another appointment. After two consecutive missed appointments, their case would be reviewed, and a clinician may have sent a letter offering the option of a third chance.

“This will clearly state that if a third appointment is [not attended], you will be discharged from the service back to your GP,” previous guidance said.

Under new rules, a single DNA (did not attend) could result in a patient being discharged.

But with a waiting list of more than 11,000 people, and wait times of around five years, it is feared many patients will not even be aware that they were given an appointment in the first place. Moreover, concerns have been raised that not enough is being done to protect the most vulnerable – those without a fixed address, or those who can’t read, for example.

The revised policy states that patients may be offered a second appointment, with clear guidance that a second DNA would result in discharge – but even this does not appear to be guaranteed.

Patients who are discharged are sent back to their GP, where they can be re-referred without losing their place on the waiting list. However, if a patient is not re-referred by their GP within six months, they will again drop to the bottom of the 11,000-person waiting list.

Tavistock gender clinic’s new ‘did not attend policy’ will hurt ‘vulnerable patients’

Notes from the GIC’s Clinical Governance Meeting seen by PinkNews show that the general manager of the clinic’s gender services, told staff that “cases will be reviewed with a view to discharge” after one missed appointment, “due to the length of the waiting list”.

Other staff at the London GIC “agreed that after one DNA [did not attend], patients will be discharged unless they make contact within one month”.

The only exception would be “mitigating clinical circumstances”, like “psychosis, assaults, [Mental Health Act] admissions, mental health crisis contact”.

A “patient friendly version” of the policy has been added to the GIC website, although it does not explain what acceptable mitigating circumstances would excuse a missed appointment.

According to the meeting notes, they “stressed the importance of prioritising patients that are serious about their care”.

However, a source employed at the GIC warned PinkNews that “vulnerable patients” are most likely to be discharged under the new policy, for reasons that have nothing to do with their commitment to their transition.

It is likely that many patients may not realise they have an appointment or even that they have been discharged after missing it, they said.

For example those who cannot read, who have mental health problems, who have housing problems, who are neurodiverse or who have simply moved house during their often years-long wait for an appointment.

According to the GIC’s website, patients are notified “six to eight weeks ahead of the actual appointment in question” by post or, if they have chosen, by text. “New patient packs” are always sent by post, according to the GIC’s website.

The employee explained that the London GIC was “not good” at updating addresses, and that they knew of one patient, seen by the clinic for years, who could not read but did not have this fact listed in their file.

While these problems preceded the change in DNA policy, the new rules put vulnerable patients at greater risk of discharge.

‘Heavy-handed’ new policy at the London GIC will ‘disadvantage’ and ‘punish’ trans folk, LGBT+ rights groups say

Mermaids, the charity for young trans people, was among those concerned by the new policy.

A spokesperson told PinkNews: “We are extremely concerned about the Tavistock Gender Identity Clinic’s recent amendment to its ‘Did Not Attend’ policy which now states that people who miss their first appointment now risk being discharged from the service and will need to be re-referred through their GP within a six month period in order to secure their place on the waiting list. This is very disappointing to hear.

“We know people can wait upwards of five years just for an initial consultation with a doctor – and many may not even be aware they have been offered a first appointment – so the fact that they could be discharged from the service altogether, and beyond the six-month timeframe, be forced to restart the process entirely, is very unfair.

“Additionally, appointments are sent out by letter which means those individuals who have difficulty reading, are neurodivergent or do not have a fixed address, are at increased risk of missing – or misreading – this letter and being discharged from the service.

“The Tavistock needs to adopt a more inclusive and mindful approach that considers the additional barriers patients might face that could result in them missing their first appointment, rather than punish people for it.”

Sasha Misra, associate director of communications and campaigns at Stonewall, added that it was important “not lose sight of the big picture, which is that trans people face dauntingly long wait times to access vital gender identity healthcare services – waits that can span over four years”.

However, she continued: “While steps need to be taken to shorten these wait times, this cannot come in the form of heavy-handed policies that have the potential to disadvantage those that cannot make their appointments for legitimate reasons – whether that be disability, neurodiversity, or circumstance.

“To face being shunted to the back of the line and wait four more years for an appointment would be devastating.

“We urge Tavistock to ensure that this policy is implemented in a compassionate way that takes into account people’s individual circumstances and needs.”

Approached for comment by PinkNews, the Tavistock and Portman NHS Foundation Trust declined to answer specific questions about the new policy, or about how it might impact vulnerable patients.

A spokesperson said: “The GIC does not automatically discharge patients who do not attend their appointments. All patients and service users are reminded multiple times about upcoming appointments, in line with their communication preferences.

“Where a failed appointment is the result of administrative error, another appointment is always offered.”

More: Gender Identity Clinics, NHS

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