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

With regards to transgender care, we followed the local guidance which is available on the Remedy BNSSG website.

A summary of our practice policy is as follows:

Shared Care Agreement:

Hormonal treatments for gender incongruence carry a lot of potential risks. Most recommended treatments are used "off label" and research evidence around the long-term impacts is still developing and remains limited. They require expert monitoring which is outside of the competence of NHS GPs.

• As NHS GPs, we would consider engaging with NHS Gender Identity Clinics where a shared care protocol is being followed and appropriate assessments have been carried out.

• The practice will not be able to prescribe hormone treatments for gender incongruence outside of an NHS shared care protocol. This includes requests from private providers, and patient-directed requests for "bridging" prescriptions.

• We would advise patients to avoid obtaining hormone medication from online sources without qualified specialist advice.

• Patients seeking treatment from private medical providers are entitled to do so at their own judgement, but we will not guarantee that we would take over a prescribing role on behalf of a private clinic.

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

We are unable to disclose how many Shared Care Agreements we hold for Transgender patients to prevent patients being identified due to the low numbers. We can confirm that we have Shared Care Arrangements in place for patients where these have been deemed beneficial to their care. However, given the specific nature of the Shared Care Agreements and small number of patients with these agreements in place, we are concerned there is a risk of identification by interference. We therefore do not feel it is appropriate to disclose this figure in line with Section 40, Exemption 2 of the FOI Act as this relates to the personal data of other individuals, and therefore would constitute a breach of confidentiality.

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?

When presented with a patient that is self-medicating without a shared agreement in place we would ask the patient to liaise with the clinic who started the medication.

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

We would not provide a bridging prescription.

Regarding blood tests, we use the Tavistock Guidance.

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?

We do not provide bridging prescription.

We want to ensure the provision of the best possible primary care for our patients. Patients who are transgender and experiencing gender difficulties (gender incongruence / gender dysphoria) often have problems which GPs are well placed to help. We can support as needed, and signpost or refer to specialist services.

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?

NHS England is the direct commissioner of specialised gender identity services for individuals with a diagnosis of gender dysphoria. NHS Gender Identity Clinics (GIC) are specialist services which involve diagnosis and care from several clinicians: typically Psychiatry, Medicine, Psychology and Surgery. Locally, we have access to this team for advice.