GPs will be paid for trans hormone prescriptions - Sussex

@MissLucyEyelesbarrow - agree, seems to me that saying "no" is regarded as being transphobic.

Saying "there is no evidence that this is effective" or "I do not have the expertise, I will refer you to a specialist" or "I do not think this treatment is appropriate for you" or "sometimes it is better to do nothing than to rush into something" is good care - difficult to deliver and it requires skill to build a therapeutic relationship and communicate the "why" so the patient buys in...but it's what GPs do daily for all sorts of people with all sorts of conditions.

Trans people being told "no" is not transphobic. Treating trans people with unproven medicine, without expertise, without a diagnosis - well, that would do harm. Harming trans people is transphobic.

Perhaps the solution here is for the trans community to reduce their expectations and have a little faith that most of society wants them to be well and happy. which would mean changing the narrative from SW et al

I treat trans patients exactly as I treat any other patient. I support patients' rights to make decisions that I might disagree with. However, as the prescriber of any drug, the responsibility rests with me to ensure that the drug is more likely to help patients than harm them. I won't prescribe a drug that I believe will do more harm than good to anyone. If I treated trans people as less deserving of this protection than other patients, that truly would be transphobia.

Refusing care to women is misogyny. Your point?

refusing care to trans people is transphobia

Meanwhile "Gynaecology waits soar by 60% during pandemic"

www.bbc.co.uk/news/health-60941950

@Kudupoo - I'm hoping the Mike Webberly findings will throw some "WTF?" into that particular mix.

Agree, no one has expertise. There are no guidelines because there is no decent evidence. So, that raises the question - "WTF are we doing?"

I saw a tweet thread about that training too - it is about ideology not evidence based medicine.

I'd be interested in what the training had to say (it isn't my area where this is being proposed currently). And in theory I wouldn't be a prescribing bot. I could do the training, assess the patient and assess the evidence and make a decision as the qualified HCP I am. Doubt I'd be signing many prescriptions. I'd like to see their rationale if they had a problem with that though.
I'm partly hopeful that GPs will be cautioned by this. At the moment there's a lot of 'oh welling'. Oh well - GPs just refer. Oh well - Psych only assess for dysphoria they don't do the prescriptions, Endo - oh well, Psych did the assessment I only prescribe the meds.
Make a GP sit in front of an 18 year old and sign the prescription for life changing, unevidenced wrong sex hormones after 2.5 hours of online training and I'm hoping enough of them will hear alarm bells ringing that this might not be the best idea or the most ethical medicine.
Conscientious objection - usually only ok if service not affected. So I personally could.maybe refuse if another GP in the practice was always available to provide the service. I don't know if it's a bit too much of a non-effectice tactic, though could get conversations started.
GMC could come at me with allegations of transphobia if they liked, not being a 'transphobe' is not my only professional obligation, pretty sure patient safety, evidenced based medicine and practicing within your competency is there too.

I feel the same @Kudupoo

I think the problem with that @Lovelyricepudding is that firstly we’re expected to keep up to date so it’s no use saying “I haven’t done the training so can’t prescribe” and the fear will still be about accusations of transphobia if we don’t do it.

Could you just not do the training so you are unqualified?

I've seen this coming and have thought about how I could conscientiously object to prescribing.

Nearly all the doctors I know are no longer members of the BMA

BMA are more than Stonewalled. A friend's training area (forgot what it is called) over recruited trainees to her specialty. They decided the seven pregnant trainees could be transferred to a different area. BMA thought this was a great way of choosing the ones to transfer.

What happens if a GP refuses to take this on because of their compentency? Is that a transphobic move, or a need for further training?

Is it currently the case that transgender patients can only get eg repeat prescriptions of testosterone from the gender clinic? Because that seems an unnecessary waste of everyone's time, especially with waiting list pressures, and something that could be devolved to a shared care pathway.

In my area practices prescribe and administer testosterone to FtM transitioners and prescribe oestrogens to MtF transitioners under a shared care agreement. I haven't come across any instances of GPs taking on the prescribing and administration of puberty blockers.

I'm not sure that the counselling offered to young people who transition is particularly thorough, going from the consultations I've had with transmen who have been surprised to get the predictable consequences of the administration of exogenous testosterone. One was absolutely insistent that they'd been told by the specialist that their acne could have nothing to do with the hormone treatment.

I think this is the Sussex document. It has a start date of 1/4/22.

www.sussexccgs.nhs.uk/clinical_documents/management-of-transgender-non-binary-and-intersex-tnbi-adult-patients-in-primary-care-lcs/

This is what it says about interim support:

2.2 Local defined outcomes
The desired outcome is that the additional needs of the TNBI population is met and that there is equity of access to services across Sussex, namely
• Initial support around gender identity issues
• Interim support whilst awaiting or under specialist services
• Provision of ongoing prescriptions of hormonal treatments as recommended by specialist GICs

It's not clear what 'interim support' means, but could be psychological support. Prescribing hormones is only mentioned in the context of ongoing prescriptions which have been prescribed initially by specialist clinics.

And about prescribing:

3.3.4 PART A – HORMONAL PRESCRIBING AND MONITORING

This LCS is not designed to promote the initiation of hormonal treatment in general practice. Regarding requests for the provision of ‘bridging hormones’, GPs should be mindful of relevant national guidance (RCGP position statement, GMC guidance, BMA guidance). Any decision to prescribe bridging hormones is a matter for the individual prescribing clinician.

In all cases, prescribing is at the discretion on the individual GP, and should only occur if the GP
• feels they have the relevant competencies to proceed
• is satisfied that any advice from secondary care or private providers is clinically appropriate

It also says: It is recognised that not all Sussex GP practices will be able or willing to provide this service. So presumably practices are free to opt out of this without penalty.

Exactly @InvisibleDragon.
My DS has ADHD.
It is really simple to diagnose ADHD but the waiting list is 2 years.
We went private after 1.
Private psychiatrist prescribed and titrated ADHD meds including changing twice due to a clash with his epilepsy meds.
Then went to shared care with the GP.
Now he's on the books of the NHS paediatrician and we see him every year or so and the GP does height/weight/BP in between.

Might be going over ground already covered here, but this does feel qualitatively different from other shared care agreements.

I'm an AHP working in mental health. It's common for a Psychiatrist to initiate prescribing a drug for a specific condition - like psychosis or ADHD - and possibly manage the initial titration of that drug, before handing over responsibility for continued prescribing and monitoring. But there would still be relatively regular contact with the psychiatrist who would take responsibility for making changes if something wasn't working well. (I realize I'm not actually sure who holds overall responsibility in these shared care agreements if something goes wrong - presumably the GP if they deviate from the psychiatrist's instructions and the psychiatrist if they ignore indications of a problem or are prescribing way out of BNF recommendations?)

In that case, the GP is basically following instructions from the specialist that are specific to an individual client. And the shared care only begins once the client has been seen and assessed by the specialist.

But the proposals for transgender patients seem quite different: that the GP should start prescribing hormones while the patient is still on the waiting list for assessment with the specialist. Which would seem to require the GP to:

• do an assessment and make a diagnosis outside of their area of expertise
• initiate prescription of a drug that would normally only be recommended by a specialist based on that assessment

Is it currently the case that transgender patients can only get eg repeat prescriptions of testosterone from the gender clinic? Because that seems an unnecessary waste of everyone's time, especially with waiting list pressures, and something that could be devolved to a shared care pathway. But that's not the same as suggesting that GPs take full responsibility for what is effectively managing the medical transition of potentially very vulnerable transgender patients, based on 2.5 hours of CPD training.

Meanwhile GPs get about £100 a year from the GMS contract to cover everything except rent/mortgage, and patients consult 8.5 times per year on average. So that's a whopping £11.76 gross per consultation to cover staff costs, heating, lighting, processing prescriptions, blood tests, referrals etc. The GMS contract runs at a loss. General practice only survives through a constant scrabble to provide enhanced services and generate enough money to keep the lights on. Literally. And the whole thing is perfectly designed to ensure that GPs working in areas of social deprivation earn less, cannot recruit, and so cannot provide decent care to patients - for which they are constantly slagged off in the media and on MN, as if it's their choice to have half the number of doctors they need.

So I'm not sure why you feel you understand the GMS contract so well, when you clearly don't. As @Faffertea says, GPs would love to be remunerated in a sensible way.

@Cuck00soup
I know you were referring to enhanced services you made that clear.
I was pointing out your assertion that you have problems around the ethics of paying GPs for things they should be doing is incorrect because if it’s not covered by GMS then the only way GPs should be doing it is if it’s an additionally funded service whether an enhanced service or something else. Whether you like the ethics or not of that is irrelevant unless you want to overhaul the whole funding situation which actually i agree with because then my practice manager wouldn’t have to spend ridiculous amounts of time claiming back money for work we’ve already done.
But as I said, I’m not going to derail the thread discussing it anymore.

Faffertea I was specifically referring to enhanced services.

But um thanks for the explanation of the GMS contract.