GPs will be paid for trans hormone prescriptions - Sussex

[Igneococcus]

I don't quite get it, supposedly it is “not designed to promote the initiation of hormonal treatment in general practice" but also "The document adds that any decision to start hormone therapy is “at the discretion of the individual GP”.
Also it seems non-binary people also need hormones.

www.thetimes.co.uk/article/eb0eb198-b1f3-11ec-8570-b43daaf58ea1?shareToken=bda8d448f411c2d44f782d823721d844

Jess I've been on one wait list 35 weeks but led to believe it could be another 2 years at least. One dc waited 2 1/2 years for treatment (now waiting potentially another year for the next step) and another dc has just passed the 18 month wait on camhs (we were seen after 9 months when they agreed therapy was necessary). If we went private for dc therapy we would be taken off the camhs list.

@Lovelyricepudding

Jess I've been on one wait list 35 weeks but led to believe it could be another 2 years at least. One dc waited 2 1/2 years for treatment (now waiting potentially another year for the next step) and another dc has just passed the 18 month wait on camhs (we were seen after 9 months when they agreed therapy was necessary). If we went private for dc therapy we would be taken off the camhs list.

The NHS cannot treat people differently for choosing to go private. I am on the NHS waiting list and also going private, with shared care from my GP. You can go private and still be on the waiting list, then switch from private to NHS.

Which could be -
A self disgust at being homosexual
Hatred of body due to sexual abuse
Mental health issues such as bi polar ect
Autistic and feels like not fitting in to society.

Yes and another is simply GNC, and has been told by teachers and/or parents that this means they are the opposite sex, and made a fuss of over their "transness". This is one that bothers me and several other women I know a lot. I would absolutely have been "transed" as a child if I was in the current climate and an in a gender-pushing school. In fact I was a tomboy who grew up to be a happy, and sometimes "tomboy", woman. I did at one point want to be a boy - simply because there were gendered restrictions on me as a girl that I didn't like. It was because I knew I couldn't be a boy that I worked through it. Many kids now literally don't know they can't actually change sex and what they're signing up for is physical damage and pain to a body that will stay the same sex.

I struggle with GP enhanced services in principle because I don’t agree with incentivising people to do the job they should be doing anyway. That said I have in the past developed local schemes to improve diagnosis - and therefore treatment of - some conditions.

This is Sussex so the public health drivers are relevant.

But unless incredibly well run, there is a risk of enthusiastic prescribing without considering the situation holistically. And 2 and a half hours online training seems barely adequate. The service may be for adults, but it doesn’t mean they are not at risk.

@Cuck00soup
That would require a radical change in the GMS contract and how General Practice is funded. The core GMS contract covers only a tiny fraction of what a GP practice does and currently the flat sum GPs are paid per patient to provide care (about £99 per patient per year) does not cover even the basics anymore. Primary care does 90% of NHS work for 10% of the budget. The managerial and administrative structure at NHS England itself gets 15% of the budget.

I won’t derail the thread but general practice funding structure is not about paying GPs to get them to do the work they should be doing anyway.

@Lovelyricepudding

Some DSDs have physical health issues. This is about the only sensible part!

This is absolutely not a sensible part. This needs specialist investigation and care.

But if the GPs are given extra money for shared care for these patients, and they have an extra annual checkup, this will be better than being completely discharged from the consultant. These patients won't need sex hormones, but an annual extra checkup wouldn't hurt.

I don't think any money body should be given hormones to try and change their sex. Too many people are in pain with disease and life threatening illnesses and these are a priority, whilst even if hormones are given people can't change their sex anyway you born male and female with the chromosomes for either male or female. My only exception to this is intersex people who are different and I don't know what help they may require

Why does Sussex so often end up at the forefront of whatever batshittery is going on in a given week? Even things which have nothing to do with local government such as Prof. Stock's harassment seem to gravitate locally.

@tootiredtobother

OFFS I asked GP for HRT, told no then went private for first prescription, and got it, now waiting to see if GP will pick up the prescription request. Why do women have to beg and fight for HRT, and these people get hormones with hardly a whimper from GP's

Was about to make a post on this - women are struggling to get HRT. Why are men able to get it?

Faffertea I was specifically referring to enhanced services.

But um thanks for the explanation of the GMS contract.

@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.

@Cuck00soup

Faffertea I was specifically referring to enhanced services.

But um thanks for the explanation of the GMS contract.

Also not wishing to derail, but you do realise that hospitals are paid on a tariff basis, don't you? They get £60 if you walk through the doors of A&E, even if you have no treatment, and about £200 for each outpatient appointment. Ringing 111 to speak to an advisor who has had 2 weeks' training and is following a script costs about £35.

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.

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

(- or just accept that the patient's self assessment is correct and give out drugs on that basis, which is a whole other mess waiting to happen)

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.

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.

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.

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.

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?

@vivariumvivariumsvivaria

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?

That's the big worry. Though, in theory, it's optional, imagine what is going to happen if a GP declines to prescribe. The patient complains to NHS England and/or the GMC - both of which are fully Stonewalled. The GP goes to the BMA for help.. but the BMA are Stonewalled too. So the reality is that GPs will feel forced to participate.

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.

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

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

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

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.

@Lovelyricepudding

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

That will doubtless be considered transphobic, though, and there is no one to back us up. Regardless of how many GPs are members, the BMA controls both national and (through Local Medical Committees) regional negotiations with commissioners. One of the national GP Committee negotiators is a TW. I've heard she's a really good negotiator and nice person, but I can't see her campaigning for GPs' right to opt-out, can you?

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.