Children will need two appointments before referral to new gender services

Children newly referred for gender care in the NHS must have been seen by a GP and mental health specialist or paediatrician first, under plans for changed services set against a backdrop of thousands waiting for appointments.

Four months after the Cass Review concluded that children had been let down by a lack of research and evidence on medical interventions in gender care, NHS England (NHSE) has laid out how the system will be “transformed”.

The plan, published on Wednesday, comes after data showed 5,769 under-18s were on the national waiting list for gender care as of the end of May.

The figures, obtained in a Freedom Of Information (FOI) request by the PA news agency, showed an average waiting time of 100 weeks and that the youngest person on the list was under the age of five.

Health Secretary Wes Streeting has branded the waiting times “unacceptable”, acknowledging the “enormous distress” they can cause.

The new services will have no minimum age requirement, in order to ensure that parents of very young children are given support through the NHS where necessary.

Dr Hilary Cass said she is “pleased” that NHSE is planning to “fully implement” her recommendations but warned that the process ahead is likely to be “challenging”.

NHSE has said:

– Up to eight new gender clinics are due to open by 2026, covering the seven NHS regions in England.

–  Each will have a nominated paediatrician or psychiatrist with overall clinical responsibility for patient safety within the service.

–  Clinical trials into the potential benefits and harms of puberty blockers will begin in the early part of next year, subject to academic approval.

– A previously-announced review into adult gender services will begin in the next few weeks and is expected to conclude within months.

Only patients transferred from the now-closed Gender Identity Development Service (Gids), run by the Tavistock and Portman NHS Foundation Trust, have been seen by the new children’s services to date.

Two hubs, led by London’s Great Ormond Street Hospital (Gosh) and Alder Hey Children’s Hospital in Liverpool, opened in April and have since seen those 236 transferred patients.

But NHSE said it hopes patients on the national waiting list will begin having appointments at the new clinics within weeks.

New patients – not including those currently on the waiting list – will have to have been referred first by their GP to either Children and Young People’s (CYP) mental health services or paediatrics, and then will be referred to a gender clinic from there.

NHSE insisted this should not add to the lengthy waits already being endured by children and their families, as their first gender clinic appointment will be based on the date they were first referred by the GP – rather than the mental health specialist or paediatrician.

While the aim is to eventually have a target of 18 weeks from seeing a GP to being referred to a gender clinic, NHSE has accepted that, with thousands on the waiting list already, it could be some years before that goal is reached.

The vision ... is to increase available services for gender-questioning young people which take a holistic approach to care, addressing the needs of each individual

The new regime is understood to be aimed at adding safety nets, rather than extra barriers, in children’s care.

This follows Dr Cass’s recommendation that care should be “holistic and personal”, possibly including screening for neurodevelopmental conditions, including autism, as well as a mental health assessment.

Dr Cass, speaking on publication of her report in April, said “ideology on all sides” had directed care, “rather than care being directed by normal principles of paediatrics and mental health”, with professionals feeling “afraid to do the things that they would normally do in any other consultation”.

The next clinic due to open is in Bristol in November, while a service in Cambridgeshire is expected to be ready in the next year.

The final plan is for each of the seven NHS regions of the country to have a clinic, with the possibility of two in the North East and Yorkshire region, making a total of eight children’s gender clinics.

Children will be able to be referred to any of the new services initially, no matter where in the country they are – in a bid to help tackle the waiting list as quickly as possible – with the centres not expected to become region-specific until all of them are open.

Gids had previously been the only specialist NHS clinic for England and Wales for children questioning their gender, and closed amid controversy in March this year after a 2021 report by the health watchdog found “significant variations in the clinical approach of professionals” and no clarity in records on why decisions had been made.

The new services will cover both England and Wales.

It is understood NHS Wales Joint Commissioning Committee (JCC) hopes to work with NHSE to consider a regional centre in Wales in the future, although no timeline has been outlined.

There remains considerable work to do, but we are already making progress on a number of Dr Cass’s recommendations

Dr Cass said: “I am pleased that NHS England is planning to fully implement the recommendations of my review and the next important step will be the most challenging – turning it into a reality.

“The vision of the review – reflected in the implementation plan – is to increase available services for gender-questioning young people which take a holistic approach to care, addressing the needs of each individual, and which put in place a full package of care which can be delivered as close to home as possible.

“Setting up a new collaborative of regional providers will also bring in leaders from professional societies, education, and research, to ensure these services continue to develop in line with evidence and best practice to support children and young people.”

Mr Streeting welcomed the further rollout of new services and the trial into puberty blockers, saying “children’s healthcare should always be led by evidence”.

He added: “I want trans people in our country to feel safe, accepted, and able to live with freedom and dignity.”

NHS medical director for specialised services Professor James Palmer said the rollout of new clinics is “central to improving and expanding NHS gender services for children and young people, to ensure that they receive evidence-based, responsive, holistic care”.

He added: “There remains considerable work to do, but we are already making progress on a number of Dr Cass’s recommendations, and our plans published today set how we will establish services that provide the care that patients and their families need to thrive.”

Professor Sir Stephen Powis , NHS national medical director, said the plan “fully maps out this new service for children and young people” which will result in a “fundamentally different and safer model of care”.

Professor Sir Simon Wessely, who chairs NHS England’s Gender Dysphoria Research Oversight Board said it will “develop and manage a new programme of research” to close evidence gaps and ensure people have the “best information possible to support their informed choices”.