This was an announced, focused inspection of the Gender Identity Development Service (GIDS) at the Tavistock and Portman NHS Foundation Trust.
The Gender Identity and Development Service (GIDS) is provided by the Tavistock and Portman NHS Foundation Trust. In October 2020, the service was working with 2093 young people. The service is based at the Tavistock Centre in London. The service has a regional centre in Leeds and satellite clinics in Exeter, Bristol and Birmingham. Most of the referrals to the service are from GPs and child and adolescent mental health services. The service also accepts referrals from other health, social care and education professionals and from voluntary organisations. Referrals are made for people under the age of 18 with features of gender dysphoria. Gender dysphoria describes a sense of unease that a person may have because of a mismatch between their assigned sex at birth and their gender identity. The gender dysphoria leads to clinically significant distress and/or social occupational and other functioning impairment. There may be an increased risk of suffering distress or disability.
The service is commissioned by NHS England. The service is commissioned to provide assessments of young people, refer young people for medical treatment when appropriate and provide some continuing support when this is required. It is a national specialist service and is the only service available in England for children and young people with gender dysphoria. The service also treats children and young people from Wales.
The Tavistock and Portman NHS Foundation Trust provide outpatient psychosocial services only, and GIDS provides outpatient services for gender dysphoria. Any medical treatment is provided by other acute healthcare providers and the Tavistock and Portman NHS Foundation Trust refer into these as required. 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 GIDS.
Our last inspection of GIDS was in 2016. This took place as part of an overall inspection of the Tavistock and Portman NHS Trust. Following the inspection, we rated the trust as good overall. The domains of effective, caring, responsive and well-led were rated as good. The domain of safe was rated as requires improvement, although the improvements we said the trust must make related to a different service within the trust.
We undertook this inspection due to concerns reported to the CQC by healthcare professionals and the Children’s Commissioner for England. Concerns related to clinical practice, safeguarding procedures and assessments of capacity to consent to treatment. This inspection focused on the Gender Identity Development Service (GIDS) only.
As this inspection took place during the Covid-19 pandemic we adapted our approach to minimise the risk of transmission to patients, staff and our inspection team. This meant that we limited the amount of time we spent at the service to prevent cross infection. Four inspectors and a CQC specialist advisor visited the service at the Tavistock Centre on 14 and 15 October 2020 to review patients’ records and complete essential checks. Two inspectors visited the service in Leeds on 20 October 2020. Whilst on site we wore appropriate personal protective equipment (PPE) and followed local infection control procedures. The remainder of our inspection activity was conducted off-site. This included interviews by telephone, the use of video conferencing facilities and analysis of evidence and documents. Our final staff interview was completed on the 6 November 2020.
Separate from our inspection the High Court made a ruling on the 1 December 2020 around capacity and consent of children receiving hormone intervention for gender dysphoria. This ruling has not impacted on our findings. Our findings and judgements are based on the legal position at the time of our inspection.
Prior to, and during, the inspection we received intelligence from former members of staff and healthcare professionals not directly associated with the service. During the inspection visit, the inspection team:
- visited the service to look at the quality of the environments
- spoke with 22 young people who were using the service
- spoke with 13 parents of young people using the service
- reviewed information from 23 people who contacted the CQC through our website to share their experience of using the service
- reviewed information from six people on the waiting list who contacted the CQC through our website
- reviewed information from six service users and parents who wanted to share their experience via an independent organisation
- spoke with four members of the GIDS clinical executive team, the GIDS safeguarding lead, the GIDS service manager, the divisional director for gender service, the medical director, human resources director and a staff governor.
- spoke with 30 other staff members across the multidisciplinary team
- looked at 35 patients’ records
- looked at a range of policies, procedures and other documents relating to the running of the service.
Our rating of this service went down. We rated it as inadequate because:
- The service was difficult to access. There were over 4600 young people on the waiting list. Young people waited over two years for their first appointment.
- Staff did not always assess and 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 risk assessments were not always in place with plans for how to manage these risks. The number of patients on the caseload of the teams, and of individual members of staff, were high making caseloads difficult to manage and placing pressure on staff.
- Staff did not develop holistic care plans for young people. Records of clinical sessions did not include any structured plans for care or further action. Staff did not sufficiently 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 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.
- The teams did not always include the full range of specialists required to meet the individual needs of the patients. Staff did not always work well together as a multidisciplinary team.
- 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.
- 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 about the care and support staff had provided.
- Staff referred young people to other providers for medical treatments that were consistent 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, and shared these with all staff.
- Clinical premises where patients were seen were safe and clean.
Following the inspection, we took enforcement action against this provider under the Health and Social Care Act 2008 by imposing a condition upon their registration. This requires the trust to report to us on a monthly basis so we can monitor their progress with improving their waiting times.