Specialist gender services for children and young people: progress report

Recruitment and Retention

32. Despite the provision of funding to date some gender identity services, including Sandyford in NHSGGC, have reported at times significant challenges in both the recruitment and retention of clinical staff. These recruitment challenges are mirrored in NHS England, as reflected upon at length in the final report of the Cass Review. It is the case that the Young People's Gender Service has been unable to fill several vacancies in recent years. This has affected how many young people who can be seen and therefore has limited the impact of work in the Board to reduce waiting lists. The reasons for challenges in recruitment and retention are varied but include the specialist nature of the field, the politically polarised context of the work with significant media scrutiny and public exposure, as well as wider national recruitment and retention issues seen across several clinical specialities. Fixed term posts have difficulty attracting experienced staff from permanent positions and wider budgetary challenges in Health Boards mean that secondment options are not always supported.

Waiting Lists

33. As published in the MDT report on 5 July, management information provided by NHSGGC indicates that as of February 2024 there were around 1,100 young people on the waiting list for the Young People's Gender Service, with patients currently being seen referred in June 2019.

34. As outlined in the MDT report, data from Quarter 3 2023 shows that at that time 1253 people were on the waiting list. Approximately 72% of them had been waiting longer than one year and 39% longer than two years with 14% waiting longer than three years. The number of young people seen per year by the service in the last five years was outlined in the MDT report.

Waiting List Management

35. As part of work to support those waiting and ensure any with unmet health needs are referred or signposted to appropriate services, NHSGGC undertook an administrative validation exercise for its young people's service waiting list. This commenced in October 2023 and was completed in February 2024. This process contacted everyone on the waiting list to check information held about them was correct and that they still wished to access the service. This process was essential to permit accurate communications with patients, especially necessary as a majority of young people on the waiting list live outside NHSGGC and a substantial proportion of the waiting list had self-referred, rather than been referred by a clinician. Where no responses were received following the administrative process, patients were removed from the waiting list in line with NHSGGC's Access Policy.

36. With the administrative validation underway NHSGGC began clinical waiting list validation processes in December 2023, following the development of a clinical validation tool. Clinical validation of the waiting list has sought to identify any unmet needs of those on the waiting list and refer those on the waiting list to additional services where appropriate, for instance CAMHS or signposting to third sector and community support.

37. These appointments have been carried out by either clinical psychologists or assistant psychologists. As of 19 August 2024, 422 young people have been contacted.

38. Analysis carried out by NHSGGC up to 19 August 2024, has found that just over 70% of validation appointments were attended. Of those who completed validation at that time 43% had self-referred, 41% had been referred by a GP and the rest referred by CAMHS or another service.

39. Further information on a snapshot assessment of the validation exercise, which continues, is given in the 'Cass Review – Implications for Scotland' report from the CMO's MDT published in July. However as of 19August 2024, 26% of validation appointments resulted in a referral to counselling and support or 3^rd sector activities and 11% an onward referral to CAMHS, GP or Social Work.

40. In October 2023, Glasgow City HSCP contracted community based third sector support for its LGBT+ population to help address social isolation, inactivity and mental and emotional wellbeing support.

41. With the additional financial resource provided by Scottish Government to address long waiting times for its gender services, an additional layer of service provision has been added specifically for people waiting for the gender identity healthcare services at Sandyford or currently accessing them.

42. This includes:

• Developing the role of a youth and community development officer to act as a dedicated worker to coordinate third sector support for young people
• An increase in staffing for trans support groups delivered in Glasgow to enable increased numbers of young people, specifically on the waiting list, to attend and removing waiting lists for existing third sector services
• An increase in the offer of 1:1 asset-based coaching both in person and online to meet increased need in Glasgow and in other areas. Previous capacity only allowed staff to respond to young people in crisis
• Increased offer of additional one-to-one practical and emotional support
• Increased offer of additional peer support, via facilitated groups
• Increased communication and understanding of the service and community need
• Delivery of a physical activity programme targeting trans young people who are in early transition and on the waiting list
• Extended provision of the peer-support available within LEAP Sports Active Buddies scheme and target and track specific provision to those on the waiting list
• A new physical activity group for young people (age 13-17).

2021 Framework – Development of National Standards

43. As well as the above provision-specific work on clinical service delivery, the 2021 Framework committed to a series of national actions which would also positively impact the overall clinical landscape. These would support improvement in both adults and children and young people provision.

44. First of these is the development and completion of national standards for gender identity healthcare by Healthcare Improvement Scotland (HIS). The aim of standards is to ensure national consistency in the multidisciplinary delivery and coordination of high-quality healthcare, in this case gender identity healthcare, based on current evidence and best practice.

45. A 13-week public consultation on the draft standards took place earlier this year and publication of its Gender Identity Healthcare: Adults and Young PeopleStandards took place on 3 September 2024. While many aspects of the standards as a whole will be applicable to services delivered to young people, the HIS standards also include a standard specific to the delivery of care to children and young people. Standards are not the same as clinical pathways, clinical guidelines or standard operating procedures, the standards, alongside the recommendations of the CMO MDT, will inform new national commissioning work outlined above.

2021 Framework – Bringing Services within National Waiting Time Standards

46. The 2021 Framework committed to bring gender identity services within national waiting time standards.

47. As consultant-led clinical services, updated NHS Scotland Waiting Time Guidance as published in November 2023 is applicable to NHS gender identity services in Scotland. This means the requirements and principles set out by the updated NHS Scotland Waiting Times Guidance apply to these services – including expectations for managing new outpatient appointments, waiting list management, validation, and ongoing treatment within the scope of the Guidance.

48. Recognising the scope of the Guidance, and breadth of the ongoing challenge being addressed across NHS Scotland, Health Boards are preparing implementation plans. Scottish Government expects that gender identity services will be incorporated into these broader Health Board implementation plans.

2021 Framework – Development of a Transgender Care Knowledge and Skills Framework

49. Following the 2021 Framework NHS National Education for Scotland (NES) were commissioned by Scottish Government in 2022 to develop a Transgender Care Knowledge and Skills Framework. Following consideration, development of that NES Framework work began in summer 2023. NES has worked with a range of stakeholders in the Scottish Government and NHS Scotland, clinicians, professional bodies, people with lived experience of accessing or waiting to access gender identity services and third sector groups to develop a Knowledge and Skills Framework.

50. On 3 September 2024 NES published a Transgender Care Knowledge and Skills Framework for Adults. Work to develop an annex to the Framework, focussing on staff working with children and young people who are trans or questioning their gender, has started and is expected to be completed in 2025

2021 Framework – Public Health Scotland Waiting Times Data

51. The 2021 Framework committed to commission Public Health Scotland (PHS) to establish robust national waiting times data collection, monitoring and reporting for gender identity services.

52. PHS are continuing to develop quarterly, aggregate data collection for NHS Gender Identity Clinic (GIC) waiting times, focussing on number of new referrals and length of wait from initial referral to first outpatient consultation with a specialist. In November 2022, PHS conducted a pilot data collection exercise with all four NHS GICs in Scotland ahead of implementation of quarterly data collection (from 1st April 2023).

53. This exercise covers both adult and young people's service. It is expected that PHS will publish a summary of its first annual data return in winter 24/25.

2021 Framework – Independent Evaluation of the Impact of Scottish Government Funding for Service Improvements

54. As highlighted earlier in March 2024 Scottish Government, following standard procurement processes, commissioned an external provider to conduct an independent evaluation of the impact of Scottish Government funding to NHS Health Boards for work to improve access to, and delivery of, gender identity services.

55. The overall aim is to understand the impact of Scottish Government investment on waiting times and quality of care at each gender identity clinic, including the Young People's Gender Service. This will include considering supportive factors or impediments to service improvement. This will help to support future development and service improvement work.

56. This work began in April 2024 and is well advanced.