The Francis Report, published on 6 February 2013 as a result of the public enquiry into the Mid Staffordshire Hospitals NHS Trust, places the onus on healthcare providers and healthcare professionals to put patients first.
It recommends a change in the culture of our healthcare system, stating: "A fundamental culture change is needed to put patients first, which can largely be implemented within the system that has now been created by the new reforms."
With this in mind, many transgender patients hope to see a change in the way they are treated by healthcare professionals, whilst the doctors treating such patients will be required to adopt a change of attitude or potentially face fitness to practise investigations by the General Medical Council (GMC).
It is clear that with progression in medical science and the laws on equality and diversity, transgender patients have the freedom of choice to request treatment for gender reassignment.
However, how are our GPs responding to these requests? Not well, according to recent research.
Treatment for gender reassignment has sparked controversy for some years, with some members of the public arguing that NHS monies should not be spent on treatment of this sort.
In 1999 R v North West Lancashire Health Authority Ex Parte A, D and G  1 WLR 977, CA made headlines as a landmark case for patients fighting for funding for gender reassignment.
Each of the three patients applied for funding from their local health authority for gender reassignment surgery, which was refused. They applied for Judicial Review of the decision.
The local health authority argued that funding for gender reassignment surgery was not as important as funding for what they termed 'real illnesses', because the desire for gender reassignment was a state of mind that could be resolved with counselling.
In a landmark decision, the Court of Appeal decided to allow the Judicial Review on the basis that the local health authority were operating a 'blanket policy' in relation to issues of gender reassignment, when the proper approach should be to consider each case on its own merit.
In 2006-07, campaign group Press for Change analysed the problems faced by transgender patients and commissioned a report - Engendered Penalties - resulting in these key findings:
- 21% of transgender patients started the process of gender reassignment by seeking help from a knowledgeable GP
- 21% of GPs treating transgender patients did not want to help
- 6% of GPs treating transgender patients refused to help
- 17% of transgender patients experienced doctors and nurses who did not approve of gender reassignment and therefore refused to provide services
- 29% of transgender patients felt that being transgender adversely affected the way they were treated by doctors and nurses and other healthcare professionals
Although these figures show an improvement in attitude of 50% from 15 years ago, it is clear that further improvements could be made.
An online survey of GPs by doctors.net on the same issue was conducted at around the same time as the publication of Engendered Penalties, and found that more than 80% of the 1,000 doctors surveyed believed transgender patients should not receive treatment on the NHS at the expense of the public.
In 2012, the Trans Resource and Empowerment Centre (TREC) undertook a pilot research project for NHS Northwest, which involved hanging posters in a sample of GPs surgeries highlighting supportive information for transgender patients and gathering basic, anonymous data about the numbers of transgender patients within each of the sample GP surgeries.
Surprisingly, the results of TREC's pilot research were hampered by obstruction from the GP surgeries and, worryingly, discovered blatant lying by practice administration staff despite the Strategic Health Authority and local management committees supporting the research project.
Although the research project failed because TREC was unable to obtain data due to the obstructive behaviour of surgeries, it served to highlight the cultural problems faced by transgender patients when dealing with their GPs.
The Trans Mental Health Study carried out in June and July 2012 obtained 889 responses from transgender patients, and was the biggest research project ever carried out in relation to the mental health of transgender people in Britain and Ireland. Its results were surprising.
They revealed two distinct groups of transgender patients: those with normal mental health, and those with mental health, including suicidal ideation and severe depression issues. Those with normal mental health were those patients who had undergone gender reassignment in accordance with their wishes; whilst those with mental health problems were those waiting for gender reassignment treatment, or meeting with obstructions getting gender identity treatment.
It would appear, therefore, that when transgender patients face obstruction from healthcare professionals, it actively causes them mental harm.
In January 2013, the press reported on a GMC investigation into the fitness to practise of Dr Richard Curtis, a private GP providing care to transgender patients at the London Gender Clinic.
It is alleged that Dr Curtis, who himself is post-operative, provided inappropriate treatment to a woman who now regrets undergoing gender reassignment treatment after having had a mastectomy and taking hormones. It is also alleged that he prescribed gender reassignment medication to patients under the age of 18 without the specialist knowledge or skills to do so. Finally, it is alleged that Dr Curtis failed to follow acceptable levels of care and breached conditions already imposed on his registration by the GMC.
This is the other side of the coin; GPs trying their best for transgender patients who are becoming accountable by the GMC and having their fitness to practise investigated seemingly for being too proactive in relation to the wishes of their patients.
The GMC's investigation of Dr Curtis sparked the launch by Cambridge Liberal Democrat councillor Sarah Brown of a Twitter campaign for transgender patients to share negative experiences they had had with doctors.
Called #transdocfail, it prompted more than 1,000 separate responses in under 24 hours.
As a result of those responses, transgender rights campaigner Helen Belcher set up a survey for transgender patients and an online questionnaire. Replies showed:
- 63% of transgender patients did not complain about the treatment they received because they did not believe they would be treated fairly
- 21% had had complaints they had made in the past dismissed
- 39% of the complaints received related to GPs
- 17% of complaints related to mental health services
- 22% related to gender specialist services
- 24% were not seeking transgender treatment at the time
Ms Belcher received more than 130 detailed responses from transgender patients, as a result of which she presented 98 complaints to the GMC in February 2013. The GMC has since confirmed that it will be investigating 39 of the complaints brought to their attention by Ms Belcher.
She also states that there were a further 15 complaints where the GMC decided not to investigate, either because too much time had elapsed since the index incident - Rule Rule 4 (5) of the General Medical Council (Fitness to Practise) Rules Order of Council 2004, which states that, except where it is in the public interest, no complaint older than five years should be investigated by the GMC - or where the doctors involved were no longer registered with the GMC.
Since Ms Belcher's meeting with the GMC in February 2013, she has received a further 11 complaints from transgender patients about the care and treatment they have received from their doctors.
With Robert Francis QC calling for fundamental culture changes to enable patients to be put first and with the GMC seemingly cracking down on those GPs who are not treating their transgender patients fairly or appropriately, can we hope to see an improvement in the care and treatment received by transgender patients?
Good Medical Practice 2013
Good Medical Practice is the guidance published by the GMC describing what is expected of all doctors registered with it. They must be familiar with Good Medical Practice and the explanatory guidance supporting it, and follow the guidance in the documentation. Failure to do so can result in an investigation being brought into the doctor's fitness to practise.
Good Medical Practice is revised every few years; the 2006 version is currently in force.
The GMC, however, appears to have taken on board the difficulties being faced by doctors who do not agree with the choices made by their patients, and by those patients who seek care and treatment from GPs who do not agree with their views.
It would appear, in fact, that the GMC has specifically tackled this problem in Good Medical Practice 2013, which was published on 25 March 2013, but which comes into effect on 22 April 2013.
In supplementary guidance to Good Medical Practice 2013, entitled Personal beliefs and medical practice, the GMC highlighted issues specifically relating to this matter and the paragraphs in which they appear in Good Medical Practice. Paragraphs 1, 48, 52, 54, 57 and 59 are the most relevant, with particular emphasis on paragraphs 52 and 57, which state:
"52: You must explain to patients if you have a conscientious objection to a particular procedure. You must tell them about their right to see another doctor and make sure they have enough information to exercise that right. In providing this information you must not imply or express disapproval of the patient's lifestyle, choices or beliefs. If it is not practical for a patient to arrange to see another doctor, you must make sure that arrangements are made for another suitably qualified colleague to take over your role."
"57: The investigations or treatment you provide or arrange must be based on the assessment you and your patient make of their needs and priorities, and on your clinical judgement about the likely effectiveness of the treatment options. You must not refuse or delay treatment because you believe that a patient's actions or lifestyle have contributed to their condition."
It would appear, therefore, that the GMC's own guidance is becoming more tailored to protecting transgender patients.
With the recommendations made in the Francis Report coming to life in the Health and Social Care Act 2012 and the changes to the GMC's own guidance for its registered doctors in Good Medical Practice, it would appear that the focus is going to shift more towards patients themselves and what they want, regardless of the beliefs of those treating them.
This can only be good for transgender patients who feel they have not received the care and treatment they expected.
The flip side of this is that the GMC will probably be tasked with the investigation of additional cases where it is alleged that an individual doctor's fitness to practise is impaired by reason of misconduct in relation to the way in which he/she has behaved towards a transgender patient seeking treatment.
If you are being investigated by the General Medical Council, or any other regulatory body for alleged impairment of fitness to practise on the basis of misconduct, performance or ill health, please contact our regulatory team.
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