The UK’s main gender identity development service for children is leaving thousands of vulnerable young people at risk of self-harm as they wait years for their first appointment, according to a highly critical report.
The Care Quality Commission (CQC) took immediate enforcement action against the Tavistock and Portman NHS foundation trust when it completed the inspection in November, which rated the service overall “inadequate” and highlighted overwhelming caseloads, deficient record-keeping and poor leadership.
The commission, which heard from young people using the service, parents, carers and staff in the course of its inspection, told the trust that services and waiting times in the Gender Identity Development Services (GIDS) in both their London and Leeds clinics “must improve significantly”, requiring a monthly report on improvements.
Last month, transgender teenagers told the Guardian of their own frustrations at lengthy waiting times for initial appointments.
The service has faced major scrutiny in recent years, with some former staff and campaigners raising concerns about the “overdiagnosing” of gender dysphoria, the consequences of early medical interventions and the significant increase in referrals of girls questioning their gender identity.
Inspectors found there were more than 4,600 young people on the GIDS waiting list, with some waiting over two years for their first appointment. GIDS has previously estimated an average of 18 months waiting time from referral. The report warned that the size of the waiting list meant staff were unable to proactively manage the risks to those on it, many of whom were vulnerable and reported self-harming behaviours.
Inspectors also found that staff were dealing with heavy caseloads, with a third of staff having caseloads working with over 60 individuals at once.
Concluding that the service was “not consistently well led”, the inspectors also reported staff did not always feel respected, supported and valued, while some said they felt unable to raise concerns without fear of retribution.
However, feedback from young people and families being seen at the service was overwhelmingly positive about the care and support provided, while the report also noted that staff referred young people to other providers for medical treatments that were consistent with good practice.
How staff recorded their work was also scrutinised: the report found that the competency, capacity and consent of patients referred for medical treatment was not consistently recorded before January 2020. The change was a result of the high court ruling in the Keira Bell case, which found that that children considering gender reassignment were unlikely to be able to give informed consent.
The report also stated that staff did not develop holistic care plans for young people, nor did they fully record the reasons for their clinical decisions in case notes.
“There were significant variations in the clinical approach of professionals in the team and it was not possible to clearly understand from the records why these decisions had been made,” the report says.
Kevin Cleary, the commission’s deputy chief inspector of hospitals, said the GIDS would be subject to further inspection: “We were extremely clear that there were improvements needed in providing person-centred care, capacity and consent, safe care and treatment, and governance.
“In addition vulnerable, young people were not having their needs met as they were waiting too long for treatment. The action we took was one way of ensuring the trust was tackling these issues in a way which allowed other healthcare partners to support if necessary.”
The report comes the day after the NHS trust was given leave to appeal against the Keira Bell ruling by the high court, which barred it from referring under-16s for puberty-blocking treatment.
A spokesperson for the Tavistock apologised to patients for the length of time they are waiting to be seen, and said the GIDS was ready to agree a full action place with the commission.
“Above all, we remain focused on providing a high quality service to children and young people in our care and supporting our staff who, despite the challenging context they have been working in, have been praised by the CQC for their understanding, compassion and kindness. Patient feedback was reported as overwhelmingly positive and we will involve both patient and staff as we build on these strengths.”