1) Are there transgender Shared Care Agreement and Bridging Prescription policy/guidance documents in use at your practice? 

In March 2016 the GMC published Guidance for Doctors Treating Transgender Patients. This guidance reiterates the advice previously set out by NHSE in SSC 1417; and also explains the legal protection against discrimination and harassment given to trans people by The Equality Act 2010 and Gender Recognition Act 2004.

Specifically, it states, “General Practitioners should co-operate with the specialist Gender Identity Clinics and prescribe hormone therapy (feminising or virilising endocrine therapy) recommended for their patients by the GIC. The specialists at the GIC make recommendations for the prescription and monitoring of these therapies but they do not directly prescribe them, or provide physical and laboratory monitoring procedures for patients. The decision on whether or not to provide long-term feminising or virilising endocrine therapy requires the skills of a gender specialist physician, usually working within a GIC.”

In 2018, a further NHSE SSC 1826 (Jan 2018) detailed the responsibility of GPs in relation to prescribing on a shared care basis with private online providers, which were increasingly being utilised by patients due to long waits for an NHS commissioned service.

NHSE advice was that a request by a private provider “may be no different” from that of an NHS commissioned specialised GIC, provided that the request is from a reputable company offering a safe service and that the health professional is an appropriate “gender specialist”

The NHSE current commissioning protocol is comprehensive and states the following:

• The assessment, diagnosis and confirmation of gender dysphoria must be by a health professional who specialises in gender dysphoria and has general clinical competence in diagnosis and treatment of mental or emotional disorders

• The decision to recommend endocrine therapy should have the documented support of two gender specialists who are directly involved in the patient's care; at least one of whom must be medically qualified and who must make the prescribing recommendation

• The provider has an effective multi-disciplinary team of gender specialists that meets regularly, either in person or through electronic communication

There may be a long waiting time to access an NHS-commissioned GIC.

Prescriptions will not be issued by the NHS-commissioned service until it has assessed and diagnosed the individual, in accordance with the current commissioning protocol. In such cases, the GMC advises GPs that if the patient is distressed, or the GP believes them to be at risk from self-harm, the GP should offer them support and consider the need for referral to local mental health services.

As advised in the GMC guidance, we collaborate with NHS GICs on a Shared Care Agreement (SCA) basis and with other gender specialists in a similar way (on a case-by-case basis), if they satisfy our criteria for being a reputable clinic and a suitably qualified gender specialist.

There are examples of shared care agreements that would be followed below.

• https://gic.nhs.uk/gp-support/shared-care-protocols/

• https://www.dpt.nhs.uk/our-services/gender-identity/for-gps-and-professionals

Bridging Prescriptions:

The GMC also describes the limited circumstances in which a bridging prescription may be considered, in cases where the patient is already self-prescribing with hormones obtained from an unregulated source (over the internet or otherwise on ‘the black market’); any bridging prescription is intended to mitigate the risk of self-harm or suicide; and the GP has sought the advice of a gender specialist, and prescribes the lowest acceptable dose in the circumstances.

Specific to bridging prescriptions, BMA guidance suggests that:

“It must be remembered that prescribers take individual ethical, clinical, and legal responsibility for their actions, and, when deciding on appropriate management, GPs should keep accurate records of their reasoning and decisions. While awaiting specialist assessment, GPs should attend to their patients’ general mental and physical health needs in the same way as they would for other patients, but are not obliged to prescribe bridging prescriptions.”

As outlined above there are very limited circumstances where bridging prescriptions provided by a non-specialist NHS GP would be justifiable. The GICs do not endorse hormone treatment prior to the comprehensive assessment and availability of multidisciplinary support, commissioned through the specialist pathway. Bridging prescriptions are very strictly a harm reduction measure, and, as such, all requests for treatment would be reviewed on a case-by-case basis at a clinical meeting.

2) How many transgender Shared Care Agreements do you currently have in place? 

After careful consideration, we have determined that we are unable to provide this requested information. The data you have requested for our practices is such that disclosing this data could potentially lead to the identification of individual patients. This would constitute a breach of their confidentiality and contravene the data protection principles outlined in the General Data Protection Regulation (GDPR) and the Data Protection Act 2018.

If managed as an FOI, we would also apply the exemption under Section 40(2) of the Freedom of Information Act 2000, which relates to personal information. This exemption applies when disclosing the information would breach any of the data protection principles.

3) When presented with a transgender patient that is self-medicating, does your service offer to monitor bloods without a Shared Care Agreement or Bridging Prescription in place? If so, what blood tests are included for those taking feminising HRT and those taking masculinising HRT?

We recognise that the waiting times for NHS GICs has increased significantly in recent years. This is leading some people to access feminising or masculinising Hormone Replacement Therapy (HRT) from other sources.

Self-medication is not advised without access to the holistic assessment and treatment plans, according to the NHS commissioning protocol. There is currently no such commissioned service for prescribing advice within BNSSG.

We follow BNSSG Transgender prescribing information for GPs which states:

“Assessment for appropriateness of medication is best placed within a multidisciplinary gender identity clinic where a full psychological assessment can be performed. In addition, it can address the requirements for gamete storage which is crucial prior to initiating any medications.

It is difficult for GPs to have an oversight of the quality assurance and clinical governance processes for all private clinics and on-line providers.”

Therefore, to ensure harm reduction and best respond to a patient’s needs, any such request for blood tests would be discussed at a clinical meeting and reviewed on a case-by-case basis, while seeking specialist advice.

4) When a Bridging Prescription is provided, what blood tests are included for those taking feminising HRT and those taking masculinising HRT?

For the reasons set out above, a bridging prescription would be provided in the context of careful consideration and at the provision of specialist advice. Clear recommendations for blood tests are provided from the specialist clinics when there are shared care arrangements in place.

Although blood tests could be arranged without a shared care arrangement, it would be the lack of access to specialist interpretation of these that would give cause for concern. There is currently no commissioned service for prescribing advice within BNSSG.

5) Bridging Prescriptions are considered a "harm reduction strategy" in transgender healthcare (Royal College of Psychiatrists (October 2013) CR181: Good Practice Guidelines for the Assessment and Treatment of Adults with Gender Dysphoria).

Does your practice advise GPs to undertake a patient safety risk assessment before issuing, rejecting or ending a Bridging Prescription?

All requests for treatment are reviewed on a case-by-case basis at a clinical meeting. Prescribing, changing, or stopping any prescribed treatment in any therapeutic area involves a risk assessment and shared decision making with the patient.

In addition, we would attend to our patients' physical and mental health needs, making a clinical assessment and, if necessary, referrals to mental health services for further assessment.

6) The GMC recommends that GPs should collaborate with gender specialists in the provision of transgender healthcare; if the GP cannot access a gender specialist the GMC states "it would not (however), be acceptable to simply refuse to treat the patient" (LINK).

If a GP at your practice cannot access the advice of a gender specialist, what is the protocol they will follow?

Regarding the provision of good quality primary physical and mental health care to transgender patients, we recognise that this group has significant need and that this is not confined to hormone treatment. We have recently sought training from a colleague who works in a GIC and are in the process of creating a protocol to ensure that we offer comprehensive and proactive primary medical care in line with the concepts of “inclusion” health, and that we are sensitive to the emotional and psychological needs of our patients and enhance accessibility to primary healthcare.

This would include (but is not limited to):

• Providing a welcoming environment at the surgery

• Signposting to the extensive support information and resources available to support social transition and emotional wellbeing/social connection and support.

• Ensuring that mental health concerns are addressed proactively

• Ensuring that patient preferences regarding terms of address (both written and verbal) are recorded robustly and utilised appropriately

• Ensuring that medical records reflect the patient’s wishes in relation to their gender identity and that they are notified on an individual basis of any NHS screening implications (and supported to access appropriate care for them in a sensitive way)

• Offering support to optimise cardiovascular and general health in preparation for hormone therapy or surgery should this be required

• Providing proactive support with contraception and advice about sexual health in order to minimise health risks and/or dysphoria

• Ensuring that they are referred as early as possible to NHS GIC services so that they can receive holistic, multidisciplinary support

If your question relates to prescribing hormone treatment, the prescribing of hormone therapy in gender dysphoria must involve an ongoing specialist multidisciplinary team providing a holistic treatment approach to the individual to ensure that they are receiving optimal and safe care. Prescribing of hormones in this context is a highly specialist treatment. Clinicians working in general practice lack the expertise and clinical competence to safely prescribe and monitor these treatments without shared care processes in place. Again, this scenario would be discussed at a clinical meeting and reviewed on a case-by-case basis, while seeking specialist advice.

Additional response

To Summarise:

I want to acknowledge the long waits for commissioned specialist NHS care in this area. In line with the recommendation by the BMA, we continue to advocate for our patients and to campaign for better provision. Furthermore, we are aware the Intercollegiate document on Transgender Care (2013) is currently being updated and we will review the contents when it is published to ensure our practices are up to date with the most recent recommendations.

I would like to reassure you that BrisDoc is committed to ensuring that all patients receive the highest standards of care.