Gender identity healthcare: evaluation of the impact of Scottish Government funding

8. Comparative Analysis

This evaluation project has asked: what have been the effects of Scottish Government funding allocated to NHS Health Boards to improve access to, and delivery of, gender identity healthcare in Scotland? Having completed our five case studies, we can assess similarities and differences across the GICs, and to explore sources of variation. This analysis will help to underpin best practice learnings for service improvement.

This project has employed a ‘most similar’ comparative research design. Here, we have examined the local health systems that have been built around four GICs in Scotland. Each GIC aims to work to the same NHS principles and standards, i.e. NHS Scotland general standards of care, the NHS Scotland Realistic Medicine vision, and the 2012 NHS Scotland Gender Reassignment Protocol (updated protocol published in September 2024). Each Board has been able to apply for SG funding for gender identity services, in line with the aims and principles of the funding. One may expect, then, that service delivery and outcomes will be broadly similar. However, our analysis has shown so far that the local health systems have produced different outcomes. Our next question is, then, why is there variation? Let us begin, however, with the similarities across the four cases.

Similar trends:

• All of the clinics are facing significant demand with long waiting lists, creating significant pressure and stress amongst staff;
• There are staff shortages / recruitment issues across all clinics, which are partly exacerbated by the short-term and fixed-contract nature of posts in GICs;
• Staff regularly reference the political climate and fear around this topic;
• There is, as yet, an absence of national clinical governance and adequate training for clinic staff and the broader NHS workforce;
• Staff are passionate and committed to supporting patients.

PHS’s analysis of waiting list times for first outpatient consultations to GICs reveals that there has been an increase of 7% in the number of people waiting across Scotland between 30 June 2023 (5,273 people) and 31 March 2024 (5,640 people). There were 1,680 referrals made to NHS GICs during 2023-24, which increased by 23% between Q1 (390) and Q4 (481). All of the GIC adult services saw an increase in the number of people waiting in 2023-24, while the YP service at Sandyford GIC saw a decrease in people waiting following an admin and clinical validation.^[110]

With regard to patient outcomes, Table 6 presents data received from service users from across all of the GICs in response to our survey, which received 74 responses. Nearly two-thirds (65%) of respondents were accessing, waiting to access or had previously accessed services at NHSGGC, which compares to 20% of respondents for NHS Lothian, 14% of respondents for NHS Grampian and 4% for NHS Highland.^[111]

The data suggest that overall, service user experiences with GICs tended to be more negative than positive, with respondents feeling that there was not a good relationship between GICs and the trans/non-binary community. For instance, a plurality of respondents (46%) said their overall experience with a GIC had been a negative one, while just under a quarter (24%) said their overall experience had been positive. Meanwhile, a slight majority of respondents (55%) felt that there is not a good relationship between GICs and the trans/non-binary community, while only a small minority (7%) said that there is a good relationship. Furthermore, most respondents to the survey (61%) said they had not noticed any changes in how gender identity services in their area are delivered since the allocation of additional SG funding.

There are therefore a number of similarities across the case studies in the challenges facing GICs, and in the experiences of service users. Yet these similarities are overshadowed by the differences in outcomes across GICs.

Differences:

• Some clinics have been able to experiment with new service delivery approaches, formalise structures around the GIC, and get strong and active buy-in from Health Boards, while others have had less success in doing so
• Some clinics have been able to integrate adjacent services and hire experienced staff, while others have had less success in doing so
• Some clinics have been able to offer training and outreach to other clinics and partner organisations, while others feel they lack training
• Some clinics have been able to reduce waiting lists, and others have not
• Some clinics have been able to expand their gender identity services and take on more patients, while others have had to reduce their services

Interview participants across the GICs described having experienced differing impacts as a result of the SG funding. Staff members at Highland and Lothian GICs felt that funding had been crucial in enabling them to expand multidisciplinary teams, which in turn has enabled them to better address lengthy waiting lists. It was felt that the onset of SG funding had played a crucial role in enabling Highlands GIC to gain a greater level of recognition and strategic support within their Health Board, with positive consequences for staff and patients. With regards to Lothian GIC, the funding was seen as having been instrumental in enabling an underfunded service to recruit and expand. Staff interviewees felt that the SG funding made it possible for staff in GICs to see the ‘light at the end of the tunnel’ with regards to the addressing of waiting lists.

On the other hand, the impact of the additional funding was met with challenges at Sandyford and Grampian GICs. With regard to Sandyford, difficulties in recruiting staff meant that it has not been possible for the large portions of the funding ring-fenced for this purpose to be spent. This was felt to have limited the efficacy of the SG funding in addressing waiting times, though the GIC has been able to utilise some of the funding on additional third sector support and to hire part-time agency staff. Meanwhile, Grampian GIC has experienced challenges in recruitment and difficulties accessing all of the SG improvement funding. They were unable to recruit the senior staff necessary to supervise existing staff and fully resume the service for a period of time.

These differences in impacts of the SG funding across NHS Health Boards, have also been identified by third sector organisations who support trans and non-binary people, and who have been collaborating with GICs to improve care. One interviewee said, “I think it’s a mixed bag across Scotland. I think half the Boards …are doing really well. They've seen their waiting lists decrease. I think [other Boards] are having a lot more problems … I think in overall terms, the trans community was really excited about the Framework and the funding. They really wanted to see a transformation of gender identity services in Scotland. I'm not sure the funding has resulted in that yet.”

Based on our analysis of the data, we have identified six key factors that may help to explain this difference in outcomes across the case studies.

8.1 Level of Demand for Services

The first factor that may support or hinder the ability of GICs to use the SG funding to make a difference to services is the level of demand. A key theme to emerge from the interviews is the existence of long waiting lists across all of Scotland’s GICs, and the frustration and stress this causes amongst staff. While some interviewees were hopeful that recently implemented changes that have resulted from the improvement funding would enable GICs to start cutting down on waiting times in the months and years to come, others emphasised the unsustainability of current waiting list lengths given the relatively small sizes of the staff teams in place at GICs.

At the same time, there is large variation in the level of demand for services across Scotland. While some clinics have waiting lists in the thousands and are overwhelmed with high demand, such as Sandyford, other clinics have lower levels of demand. This is largely due to the population size of the area that the GIC is providing services to (comprising the host Health Board and referring Health Boards). As one staff member observed, “I’m mindful that I’ve been involved mostly with smaller services and when I think of the central belt, then the obvious bigger problem is to do with the numbers ... it’s just enormous” Another staff member similarly felt that the smaller population size and lower levels of demand in non-central belt areas made services more manageable, “even though proportionally they have less time as well.”

In addition to variation in the population size of areas being serviced by GICs, there has been another factor that has exacerbated differences in the level of demand: notably, the variety of services that clinics are offering. While three of the clinics (Lothian, Grampian and Highland) are offering Adult Services only, one clinic (Sandyford) offers both Adult and Young People’s services. In addition, while Highland, Lothian and Grampian are open to GP (and often, mental health) referrals, Sandyford GIC has also accepted referrals from other GICs for its services (and until recently, self-referrals).

Service delivery also differs across the GICs in ways influenced by the characteristics of the geographical areas they cover. Highland GIC, for example, makes extensive use of ‘Near Me’ online consultations to support patients who live in more remote/rural areas, and the use of treatment rooms in different areas to allow patients to have blood tests locally if they live far away from the GIC. During our learning event in August 2024, staff from GICs across Scotland highlighted that demand and capacity planning was ‘really key for any service’, and suggested that ‘having a core baseline [of] key staffing inputs, demand and capacity’ is only part of the picture.

8.2 Culture and Leadership

The second factor that may support or hinder the funding being able to make a difference is the varying styles of leadership and culture across the GICs. It is important to acknowledge, however, that due to the organic development of the GICs, leadership and strategic oversight differs significantly between clinics.

Clinical leadership was noted as a key factor for building a positive workplace culture, which in turn could determine the success of the service. There is a significant challenge, however, with recruiting clinical leads into services. In one GIC, recruitment for a clinical lead has occurred three times, with the last round of recruitment receiving zero applicants. A lack of clinical leadership is seen as a significant issue by staff members, with some feeling as if they have to ‘take on’ the role. The lack of clinical leadership was equally echoed within our learning event, with staff highlighting that this has caused significant barriers to using the funding in the way they intended. The lack of management had led to some staff feeling as though their clinic ‘look[s] awful’ compared to other GICs, while staff at other clinics suggested that their recruitment challenges for the clinical lead position contributes to feeling ‘exposed’.

Additionally, it was highlighted by staff that there is a lack of clinical leadership at the regional Health Board and national levels. For instance, interviewees said that the National Gender Identity Clinical Network of Scotland (NGICNS) was itself facing recruitment issues, leading to a pause in activities. This has meant that this key forum for clinicians and other staff to come together has been placed on hold. “The NGICNS was where people would come together. But that's kind of sitting in the ether just now, because there’s no clinical lead.” The need for clinical leadership was highlighted by staff in NHS Highland, who recognised that the field of gender identity healthcare is complex, requiring both an MDT approach and a dedicated point of contact.

It was not just clinical leadership, though, that was cited as a critical element of a successful GIC. Service management itself is an equally important factor, as it is this leadership which sets the tone for the day-to-day operations of a GIC. Some staff felt that managers were not as proactive as they could be, and that this in turn was an impediment to the development of the clinic. Given the small size of gender identity services, key staff can have a disproportionate impact on the success of clinics. Comparatively, staff at other clinics felt the GIC had a very positive culture, defined as a willingness and readiness to go above and beyond for their patients, which helped to underpin a ‘strong team’ and positive leadership.

In order to build a cohesive culture and team at every clinic, some interviewees felt it may be helpful to review their current makeup. Across the system, staff commented on the different structures of their teams, and a number of staff members highlighted the part-time and temporary nature of job roles as a key feature that contributed to difficulties working within GICs. Some staff members also felt teams were not cohesive enough, due to losing key staff who “understood what was going on’.

Team structure was also discussed during the learning event, with staff suggesting that challenges in “getting people together because we are part time” contributed to difficulties in building a cohesive team. This, in turn, led to some staff feeling as if “continuity and stability, sustainability and juggling availability” became difficult. Most importantly though, for teams that didn’t feel cohesive, or where there was a lack of clear leadership, the overall culture of the GIC felt unsupportive.

“Yes, I think the team needs quite clear leadership. It needs someone ... because it needs to feel safe for people. Because a lot of the time it doesn't. They need someone experienced to go to for advice, especially when they're new to the service ... So many people have left. We used to have a fairly stable core group of people.”

Wider organisational culture and societal factors were discussed by almost all of those interviewed. For some, there was a sense that the culture of the wider organisation needed to ‘catch up’ with society, reflecting the changes that are occurring with the younger generations. Language use and fear of upsetting people or ‘getting things wrong’ were reflected across the majority of those interviewed, suggesting that to improve the culture of individual GICs, fear should be removed from the equation.

8.3 Staff Capacity and Skillset

The third factor contributing to the difference between clinics is staff capacity and skillset, including training. One important finding to emerge from the interviews was the extent to which Scotland’s GICs differ regarding the number of staff in each service, as well as the kinds of skills and areas of expertise possessed by existing staff. Staff at all levels have mentioned in the research interviews that training and education are significantly lacking in the NHS and on university degree and CPD healthcare curricula. This lack of training itself leads to a much ‘smaller pond’ in which to recruit from, and combined with the temporary nature of job contracts on offer, results in a much smaller number of available staff to work in the clinics, leading to strains on general capacity.

Across the health system, the differences in capacity of the individual GICs cannot be underestimated, with core staff at clinics ranging from 13.0 WTE (at Lothian GIC) to 2.0 WTE (at Highland GIC), impacting on teams’ abilities to reduce waiting lists quickly. The mix of teams also varies across GICs, with some more focused on psychology and psychiatry staff and others more GP or nurse focussed. This has led to different care pathways for services and approaches to reduce waitlists.

Recruitment difficulties were a common theme highlighted across the interviews with GIC representatives. In addition, where GICs had been able recently to recruit new staff, they reported often facing challenges ensuring that these staff were sufficiently trained in relation to the provision of gender identity healthcare. Concerns were also expressed about the short-term nature of the funding, which meant that they could only advertise fixed-term posts, which created hiring difficulties in attracting highly skilled and qualified clinical specialists.

8.4 Healthcare approach

The fourth factor we have identified is that clinics have adopted different approaches in the development of their services. It was acknowledged that nearly all clinics had developed organically, based on increased demand and need. Feedback from our learning event showed that individual clinics differed in their views on different healthcare approaches. For some, having different approaches was a negative thing, highlighting a lack in strategic oversight and a challenge to be overcome, whilst for others, it was seen more positively and aligning with other medical specialisms.

An important point of difference to emerge between the GICs was around their places within their local health systems/structures. In particular, Highlands, Lothian and Sandyford GICs each sit within Sexual Health in their respective Health Boards, while Grampian GIC sits within Mental Health. This has led to differences in operational delivery. At the same time, all of the GICs have adopted a multidisciplinary approach, which was seen to be a strength of services. Many interviewees felt that by creating teams which can become less specialised and more generalised, a wider range of skill sets can be incorporated into the clinics, leading to a more holistic overview of patients’ needs. This move into multidisciplinary working was recommended by the SPHN report^[113], which stated that, “there was some discussion around expansion of the workforce and de-specialisation…with suggestions raised that it may no longer be necessary for services to be run by psychiatry. Alternative suggestions were for the service to be owned by sexual health or to be entirely multidisciplinary.”

Another important aspect of the different approaches of the clinics is relationships with GPs. Lothian is the first Health Board to finalise two Shared Care Agreements (SCAs) with GPs, which is being closely watched by the other services. SCAs are seen by many interviewees as a crucial step in the development of gender identity services, which in turn would support the stretched capacity amongst GIC staff. However, interviewees felt it was also important to ensure that GPs are adequately resourced to undertake new work under SCAs, to avoid over-stretching their own capacity.

8.5 Governance and Partnerships

The fifth factor that may support or hinder the SG funding being used effectively is governance and partnerships, especially the extent and nature of Board support. It became clear during the interview process that staff from across the system felt that clinics have received different levels of support from Boards. Furthermore, differing systems of governance and oversight within Boards have created systemic issues across clinics. For some GICs, they felt they received little Health Board support, others felt they received full support, and others yet felt that their Health Board had become ‘more interested’ in the service as a result of the SG funding.

Staff at one GIC felt that the SG funding has allowed for the visibility of the clinic to be raised, leading to a sense that members of senior management within the Health Board have now ‘noticed’ the clinic, which has allowed for more infrastructure to be created around the service. This, in turn, has led to a better relationship with the Board. For another GIC, however, staff within the clinic suggested that the service did not seem like a priority for the senior management within the Health Board, and that there was a lack of effective data collection and monitoring. The differing levels of interest between the Boards was also discussed at length during the learning event, with one participant highlighting that for them “the Boards could help us to know that they have our backs” and another participant feeling that, “it seems as if the Boards care more about negative publicity than they do about actual patients, sometimes.”

Based on the interviews and surveys conducted, improved links with the third sector was seen to be of key importance in improving service delivery. It was discussed by both healthcare professionals and those within the voluntary sector that GIC-third sector links needed to improve, and that providing greater support for community services was felt to have the potential to reduce demand for specialist services. Again, though, there was variation in the access GICs had to third sector partners. While GICs in the central belt tended to have stronger relationships with the third sector (with national LGBTQIA+ organisations often headquartered nearby), in NHS Highland a strong desire to improve relationships with the third sector was hampered by the lack of local third sector services currently being offered within the area. The GIC has, however, been able to recruit more staff admin time to work with organisations.

Across the clinics, there was a desire to rethink the current system of gender identity clinics, with a move towards a more local level of service delivery. Currently, the young person’s service is centralised to Sandyford, which has resulted in significant demand. A move to a more decentralised, locally based service provision for young people was recommended by the Scottish Government CMO MDT report in July 2024:

“For the Scottish context there are some opportunities to expand capacity through a distributed service model, based in paediatric services and with strong links between secondary and specialist services. We recommend these [service structures] are based on the principle of ‘as local as possible and as national as necessary’ which should apply to the provision of these services as it does for other NHS service planning, recognising that the best care can usually be delivered close to home by local universal and specialist services with prompt access to expert input where necessary.”^[114]

This recommendation to provide more local, decentralised gender identity services was also reflected in the SPHN 2018 report for both adult and YP services, which found “clear support for more services to be provided locally for both adults and young people”, with satellite or virtual clinics as a potential way of addressing inequalities of access. Individual staff members across all four of the GICs echoed this, with many advocating for a move to more local service provision:

“Could there be smaller versions? Yes, I think there could, with appropriate training and supervision and structure ... I almost find it mind-blowing that it’s not happened… there has to be a much more systematic overview of the whole system.”

Participants highlighted certain teams within the NHS as playing a crucial role in the delivery of services such as Psychology, Endocrinology, and Sexual Health services. Meanwhile, GP services are involved both in making referrals to GICs and often in the ongoing routine monitoring of GIC patients. Interview participants reported on the differing levels of strength in relationships with different GP services. Some GIC staff interviewees highlighted how GPs felt they were insufficiently trained in gender identity healthcare, and had a ‘fear of getting it wrong’ while others emphasised the strain that GPs were under, who may not have capacity to undertake additional work such as blood tests. Both GIC staff and GPs interviewed for this project felt that Shared Care Agreements - that provided clarity of roles, adequate resources for both sides, and efficient IT systems for data-sharing - would help to improve patient care.

Some interview participants from GICs discussed having leant on colleagues across other GICs for advice and support, while others mentioned having carried out scoping of other services and having attended national consultation groups. Feedback from the learning event highlighted that staff members felt that knowing ‘more about what other Health Boards have been experiencing’ would have been beneficial to their service delivery. By sharing the experiences of other Health Boards, staff described a sense of shared experience, with one staff member saying that “we’re all facing challenges, no one has a perfect service given the pressures we’re all under.”

8.6 Negative media attention

A similarity between all four of the GICs are concerns regarding negative media and political attention, and how that contributes to fear and uncertainty amongst patients as well as some staff. However, some clinics receive more public/media attention than others, which in turn, feeds into feelings of stress and even fear for staff working in clinics. Sandyford has been at the centre of public attention more than the other GICs, creating additional stress for staff currently working within the clinic. Staff members have significant concerns about ‘their names appearing in the papers’, and newspapers ‘plucking’ staff members’ names ‘out of thin air’, which unfortunately has already happened for some of the team members. This, unsurprisingly, has a detrimental effect on the ability to hire staff into the service. In the words of one interviewee: “you are not going to give up your permanent contract to come and work in the gender service when you could end up on the front of the Daily Record.”

Those who were interviewed acknowledged the difficulties of working in a service where media attention is often negative and contentious, and political debate is polarised. Incentivisation, therefore, may be a requirement when recruiting into the service, ensuring that staff wellbeing is equally prioritised.

“It can be quite a hard area to work in because of all the media stuff going on and all the different points of view on the topic. And yeah, I think that that needs to be acknowledged as well ... How can we incentivise people to come work with us? I think having a bit more permanent sustainability of the service would help with that.”

8.7 Conclusion

In conclusion, while there are key similarities between the clinics, there are also significant differences that impact the day-to-day running of these services, each of which represent factors that may support or hinder the extent to which SG funding has been able to make a difference in processes and outcomes.

Firstly, it is important to recognise that each of the clinics serve different populations due to both numbers of prospective patients and geographical variations. The central belt hosts the majority of patients, whilst more remote and rural locations such as Highland have a smaller population of patients to support. This, mixed with a wide variety of services on offer, has led to uneven demand based on location of services.

Culture and leadership, equally, differs across the systems, with some clinics having positive workplace cultures, whilst other staff feel that the workplace culture in the GIC is more strained and less cohesive. This, in turn, directly impacts service delivery. Education and training also varied across the clinics, with some GICs having highly experienced staff members in place, allowing them to even offer training to others, whilst other clinics had lost staff with previous gender identity experience. Across all clinics it was acknowledged that training was a significant ongoing need, with suggestions to create a specific curriculum for healthcare professionals interested in working in the area. Due to the lack of training and education, there is a much smaller recruitment pool to pick from, a concerning issue when considering growing demand.

Due to the organic development of gender identity clinics, clinics sit within different services and Health Board directorates. This, in turn, has led to variations in care approaches, whether it be a more nurse-led focus or more psychology focus. Shared care agreements with local GPs have been finalised by one clinic and staff felt - across all GICs - that shared care should be implemented in order to reduce demand on clinic staff. Improved relationships between clinics and senior management have been noted in most clinics, however, for those where this has not been possible, it seems that there is a need to review why this occurs, and what possible solutions could be implemented.

It is known that staff are increasingly facing incredibly fractious and politicised media coverage, which fundamentally has a detrimental effect on the wellbeing of passionate and dedicated staff members. Whilst the individual clinics face different levels of coverage, the fear associated with this is significant, and ultimately has a role to play in recruitment and retention challenges associated with working in Scotland’s GICs.