GPs are being asked to conduct ‘extensive reviews’ for patients referred to gender identity clinics (GICs) due to long waits to access services, the BMA has said.
In new guidance, it said that while GPs should ‘understand gender incongruence and the issues involved’, there is a need to ‘balance what can be expected of GPs and the expertise which should rightly remain with specialist services’.
The BMA has called for better commissioning of specialist services to avoid ‘significant’ extra workload for ‘already crumbling’ practices.
It also warned of GPs being asked to prescribe hormones for patients with gender incongruence ‘both before and after specialist involvement’.
GPs can refer patients directly to gender identity clinics (GICs), which provide patients with access to a multidisciplinary team, without an assessment by mental health services prior to referral.
However, a new BMA document on the ‘Role of GPs in managing adult patients with gender incongruence’ said that the BMA has ‘concerns about the lack of specialist service provision, the impact this has on patients and the pressure it can have on practices’.
The document said: ‘There have been reports of some GICs asking GPs to review patients who had already been referred to the GIC, due to long waiting times.
‘It is the responsibility of GICs to manage their waiting lists – not practices – and they should be approaching patients directly to explore whether they still want access to their services.’
It added: ‘Practices have been asked to do extensive review including a mental health assessment confirming if the patient still needs their services and the GIC has also written to the patient to confirm the ongoing need and to discuss any issues with the GP.
‘This work is not part of GMS services and is adding a significant workload for each patient for practices already crumbling under pressure.’
Verifying waiting lists ‘has never been the role of GPs’ and the initiative should be funded ‘similarly to local pathways for support and funding to introduce local measures on other waiting lists’, the BMA said.
It added: ‘This is another example of the urgent need for commissioning of GIC services as well as a commissioning framework of mental health services both in children and adults, so that they work in unison.’
Meanwhile, the BMA also said it is ‘aware that GPs are sometimes asked to prescribe hormones for patients with gender incongruence both before and after specialist involvement’.
The guidance said that the RCGP has backed a Royal College of Psychiatrists suggestion that GPs prescribe a ‘bridging prescription’ until the patient is able to access specialist services, as a ‘harm-reduction measure’.
But the BMA argued that GPs are ‘not obliged to prescribe bridging prescriptions’ although they should attend to their patient’s ‘general mental and physical needs’ while they await specialist assessment, as with any other patient.
The BMA said: ‘Patients should not have to resort to self-medicating due to a failure to commission a timely specialist service and we continue to advocate for NHS England and NHS Improvement (NHSE/I) to make proper commissioning arrangements.
‘If the delay for specialist assessment is excessive, GPs do have a role as their patient’s advocate in making representation to the commissioning organisation to help ensure timely provision.’
In a statement issued last month, it added: ‘Access to these specialist services should be rapid in order to ensure patients receive safe care – and if timely access at a GIC (Gender Identity Clinic) is not possible – additional intermediate capacity has to be commissioned locally to ensure safe and effective care pending specialist involvement.’
It also said that NHS England has ‘neglected to commission comprehensive, local, quality-controlled specialist services for the ongoing care of patients once they have been discharged from the GIC’.
The BMA will continue to call for NHS England to develop ‘national guidelines and properly commissioned services for this particular group’.
It has also issued updated guidance on inclusive care of trans and non-binary patients.
Brighton GP partner Dr Samuel Hall, who has a specialist interest in transgender health, told Pulse that GICs are ‘underfunded, poorly resourced and mostly hosted by hostile mental health trusts’.
He said: ‘Since the de-pathologisation of gender incongruence, there hasn’t been any move by NHS England – whose responsibility it is to commission this work – to try and facilitate a push down into primary care or general practice for treatment.’
Dr Hall, whose practice has around 450 trans and non-binary patients, added that transgender healthcare and in particular prescribing hormones is ‘not specialist care’ and that GP practices are the ‘right place’ to deliver it, but need more training and support.
He said: ‘[Providing] hormones to trans people is within the remit of any GP because we provide hormones to lots of people for lots of reasons all the time.
‘It’s just a matter of a small amount of additional learning for a GP, which happens all the time in general practice when new things crop up, to manage the hormone treatment of transgender people. It’s not very difficult basically, it’s not rocket science.’
He added that the ‘key to this is to educate GPs’ who feel ‘a little bit underskilled’ and ‘at risk of being persecuted’.
He told Pulse: ‘From my perspective, what you’re looking at here is discrimination – it’s targeted, deliberate, obstructing trans healthcare so that people can’t get what they need and it’s a way of punishing an oppressed minority group of people by depriving them of adequate healthcare.’
In 2019, the RCGP called for a whole-system approach to improving NHS care for trans patients, including more training to support GPs and for waiting times for GICs to be addressed.
This story first appeared on our sister title, Pulse.