The Care Quality Commission (CQC) has told Tavistock and Portman NHS Foundation Trust that services and waiting times in the Gender Identity Development Services (GIDS) in both their London and Leeds clinics must improve significantly.
Inspectors carried out an announced, focused inspection at the trust in October and November due to concerns reported to CQC by healthcare professionals and the Children’s Commissioner for England. Concerns related to clinical practice, safeguarding procedures, and assessments of capacity and consent to treatment.
At this inspection, the GIDS were rated Inadequate for being well-led and responsive to patient’s needs, Requires Improvement for being safe and effective, and Good for being caring. Overall the service is now rated as Inadequate.
The CQC issued requirement notices for person centred care, capacity and consent, safe care and treatment, and governance regulations. Following the inspection, CQC used its enforcement powers to impose conditions on the trust’s registration. The conditions applied to the trust’s registration are: The trust must provide a written report each month setting out:
- The actions taken to ensure the systems in place for the management and reduction in the GIDs patient waiting list are effective.
- The results of any monitoring of the system undertaken by the trust.
- A report of the number of patients on the waiting list, including monthly figures of new referrals awaiting an assessment, those assessed and receiving treatments, and patients discharged or referred onto another service.
The Tavistock and Portman NHS Foundation Trust only provides outpatient mental health services. Any other medical treatment which is needed is provided by other healthcare providers. The Tavistock and Portman NHS Foundation Trust refers into these services as and when they are needed.
Medical treatment involves the prescribing of medicines that pause the physical changes of puberty and hormones that alter characteristics of gender. This medical treatment is provided by the endocrinology departments at University College Hospital London and Leeds General Infirmary. The CQC inspected and published reports on these services at the same time as the inspection and publication of gender identity services. These reports can be found in the hyperlinks at the bottom of this release.
Kevin Cleary, CQC's Deputy Chief Inspector of Hospitals, said:
"When inspectors visited the Tavistock and Portman NHS Foundation Trust GIDS in October, we identified significant concerns and took enforcement action by imposing conditions on the registration of the trust.
“We fed back our concerns to the trust and also to NHS England and NHS Improvement. 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 trust leadership team knows exactly what improvements are needed and we will continue to monitor the trust extremely closely during this time. We will return to inspect services and expect to see these improvements in place and be thoroughly embedded."
- There were over 4,600 young people on the waiting list. Some young people waited over two years for their first appointment.
- Staff did not always manage risk well. Many of the young people waiting for or receiving a service were vulnerable and at risk of self-harm. The size of the waiting list meant that staff were unable to proactively manage the risks to patients waiting for a first appointment.
- For those young people receiving a service, individual assessments were not always in place with plans for how to manage risks.
- The number of patients on staff caseloads were high. This made caseloads difficult to manage, placing pressure on staff.
- Staff had not consistently recorded the competency, capacity and consent of patients referred for medical treatment before January 2020. However, since this date these decisions had been recorded.
- Staff did not develop all-inclusive care plans for young people. Records of clinical sessions did not include any structured plans for care or further action.
- Staff did not 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.
- Staff did not always feel respected, supported and valued. Some said they felt unable to raise concerns without fear of retribution.
- The service was not consistently well-led. Whilst areas for improvement had been identified and some areas improved, the improvements had not been implemented fully and consistently where needed.
However, inspectors also found;
Staff treated young people with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions. Feedback from young people and families currently being seen at the service was overwhelmingly positive in terms of the care and support staff had provided.
Staff referred young people to other providers for medical treatments that was in line with good practice.
Managers ensured that staff received training, supervision and appraisal. The service treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with staff.
The NHS will undertake an independent review into gender identity services for children and young people. The review will present recommendations to NHS England and Improvement’s Quality and Innovation Committee. The Gender Identity Development Service is a national specialist service and is the only service available in England.
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