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

9. Best Practice Learnings

This section presents some learnings, based on best practice from this evaluation. There are 17 learnings in total, in areas that have supported improvement work across the cases, which apply to three levels: the local (clinic) level, the regional (Board) level and the national (all-Board) level. We have chosen this multi-level approach to reflect the reality of service delivery and funding decisions across the NHS and SG, and to emphasise the principles of decentralisation in Scotland, where decision-making is made at the most appropriate level.

9.1 At the local level

What changes may be implemented at the local (clinic) level to support improvement work, when appropriate funding, infrastructure and clinical support are in place?

(1) Fostering a healthy, cohesive team culture

As with any organisation, it is important to foster a healthy, cohesive and collaborative team culture in order to boost morale, embed trust in relationships and enable effective communication, which then supports team performance. However, this factor is especially important in the area of gender identity health services, due to the extreme pressure that staff are under and the media attention the topic has been given.

Interviewees have told us that several factors may prevent the development of a healthy, cohesive team culture. These include the absence of full-time permanent staff posts and over-reliance on part-time and temporary staff posts, which often means that the team are all working on different days of the week (making meetings difficult); poor communications across the team; the absence of leadership positions within the team; the need to be constantly focused on bringing down the waiting lists (which pushes out less urgent but important time for reflection and team development); high levels of staff turnover; and the lack of training and development opportunities, which makes bringing new members into the team more challenging. Clinics that have addressed these areas have been able to build strong, healthy teams.

(2) Getting the right staff mix

All the clinics are experiencing challenges in recruiting new hires into the gender identity service teams. Staff interviewees shared that there is a dearth of gender specialists across the UK, and competition for these staff is high. The new Transgender Care Knowledge and Skills Framework, and education and training opportunities for staff in clinics and across the UK, should help to meet demand for specialist roles. Interviewees have shared other views on how to ensure sustainable well-staffed gender identity services with the right mix of skills. The most important factor, for many, is to ensure that each GIC has a clinical lead (which has been held by speciality doctors, psychologists and nurse consultants at GICs) who is incentivised to work on a permanent or full-time basis, graded appropriately, and provided with development opportunities. The clinical lead role is a complex one, as it requires working across NHS disciplines/services, representing the service to the Health Board and other organisations, and making decisions about care pathways, staff training and clinical governance in an area of healthcare that is relatively new and significantly underdeveloped. One interviewee said: “It's obviously quite a complex clinical area in terms of getting different areas to speak with one another, and they're spread across different disciplines. So I think that it’s really critical to have clinical leadership.”

Aside from the key clinical lead role, interviewees felt that there could be more flexibility in the staff mix to enable nurses to take on a greater role in conducting initial reviews, assessments, and regular treatment. It was felt that nurses often had the advantage of being flexible and often open to re-training in gender identity. One interviewee also said that there could be potential cost savings by hiring more nurses than consultants: “You need really good lead clinicians, someone that’s very knowledgeable and able to make those clinical decisions and take accountability for things that the team does. But underneath that, I think having nurses who are able to take on quite a high level of accountability, are essentially cheaper than a psychologist ... And nurses see themselves as someone that could work in any of those departments.”

Beyond this, some interviewees felt it is for staff to have ‘certain values’, such as being open-minded, curious and non-judgemental, in order to enjoy working in gender identity services. For instance, one interviewee, when asked about what they thought the right staff mix was for the GICs, said that: “In gender identity services, we are your most non-judgmental people. Because of the area we work in, we're gynaecology, we're vasectomy, we're abortions, we're sexual assault, we’re LGBT. Sexual health encompasses all of those things. And I think that those types of clinicians are a good fit for taking care of people who are trans.”

(3) Appropriate grading for staff

For a successfully functioning gender identity service, interviewees felt it was important to have “appropriate posts that are appropriately graded and have an appropriate number of hours, because this is a problem across Scotland.” All of the clinic teams we spoke to were working overtime on an unpaid basis, in order to support patients. One staff member shared that, “people are trying desperately to do a huge volume of work in a highly complex area on, you know, skeleton hours. It becomes almost impossible ... How can you attract staff to a service when they could do an equivalent banding job? That's frankly a lot easier for them to do, like we have to actually attract people into the service. So in my view, there has to be jobs that are banded at an appropriate level and therefore attractive to potential staff.”

(4) Staff safety

Interviewees for this project have stressed that it is vital that staff - and patients - feel safe when delivering and accessing gender identity services. There has been significant public, political and media attention on this issue, which has resulted in demonstrations taking place outside one GIC and attempts to harass staff and patients. It is vital that staff and patients feel safe when entering and leaving clinic buildings.

However, there are other aspects to staff and patient safety that deserve attention. For staff, there is a need to ensure that they have all of the support, protocols and supervision in place so that they’re able to work effectively and make the right decisions. This is underpinned by having clear clinical supervision, a healthy cohesive workplace, and appropriate training, resources and infrastructure, and supporting staff wellbeing. As one interviewee said, “the staff need to feel safe that they can do this complex job safely, so that it all filters down to the patients.” It is also important for staff to feel supported and psychologically safe when sharing any concerns about service delivery within their team or Board, or sharing recommendations for how to improve services. There are also safety issues to consider when thinking about the small staff size of the GIC teams, and what should happen should more than one staff member be absent. Risk assessments or business continuity plans are helpful to put contingencies in place to ensure that other staff members can continue the work.

Finally, GIC staff have stressed the need to ensure the safety of patients, especially in accessing clinics. Beyond the issue around protests described above, interviewees shared that some service users, especially those living in remote and rural locations, may have to travel on three buses over several hours to visit the clinic for treatment. This may be challenging for some patients who are also experiencing anxiety, or who may be struggling to deal with the political climate and stigma around this issue. Patient safety therefore may be best protected in collaboration with primary care providers (discussed below with regard to shared care agreements with GPs).

(5) Staff wellbeing support

Staff interviewees from all GICs shared with us how they are dealing with high workloads, high stress levels, and additional pressures due to political scrutiny and adverse media attention and public protests. “I think that it’s probably helpful to highlight that a lot of the staff feel quite weary. You know, working really hard trying to think of what to do and how to do it. And you know, people get tired. You know, I think burnout is quite a significant risk…it’s difficult to be putting your head above the parapet in a clinical area that a lot of clinicians don't want to touch.”

Interviewees suggested that a greater focus on wellbeing could mitigate the risks of burnout, including appropriate staff wellbeing tools and resources, in addition to having a manageable workload, clear role description, supportive line manager, and a sense of autonomy. If staff in GICs were to (continue to) experience high levels of chronic stress when working in the service, this may create challenges for staff retention, thereby compounding many of the recruitment issues GICs are facing.

(6) Continuous improvement ethos

A key aspect of the SG funding was its emphasis on continuous learning, especially through engagement with service users. While there was some evidence of GICs measuring and monitoring the patient experience, or systematically using patient feedback to improve services, others said they simply did not have the resources to do so. GICs that have the capacity and resources to work more closely with service users to improve services, are able to create more person-centred and flexible clinical pathways, and ensure that service users feel included, valued and welcomed.

(7) Clear communications with service users

The data collected for this project suggests that service users have more positive experiences of accessing gender identity services when there are clear and regular communications from GICs. This was found to be an area that could be improved upon across all Health Boards. Respondents to the service user survey drew attention to the sparse communications from GICs while on waiting lists, and while waiting between appointments, and the negative impact this had on wellbeing (such as feeling ‘forgotten about’ or that the clinic ‘didn’t care about them’). Several of the GICs also acknowledged that communications with patients was an area that they wished to improve, but that they often lacked the staff capacity and resources to do so. Some staff suggestions included working more closely with third sector organisations to support (and communicate with) people on waiting lists. One GIC also found that extending the hours of current staff to focus on the management of waiting lists and communications with patients led to a more positive service user experience.

9.2 At the regional level

What changes can be implemented at the regional (Health Board) level, if appropriate funding, guidance and leadership from the national level are in place?

(8) Proportionate workloads

This best practice suggestion relates to the unsustainably and overwhelmingly high levels of demand at some clinics, compared to other clinics. Some interviewees have described this as a ‘postcode lottery’, whereby “the time you wait is based on where you are in Scotland, and I know that’s across the board. But someone's waiting eight years compared to two years [to access GICs]. That just doesn't seem right.”

Managing demand for services more effectively requires a whole-system perspective from the national level, to take into account (1) the population size of areas being served by clinics, (2) the number of Boards referring into clinics, (3) specific needs of service areas, i.e. remote and rural locations, high proportion of socioeconomic deprivation, or high proportion of people experiencing other forms of disadvantage, and (4) the number and variety of services being offered. The data collected for this project suggests that the pressures and workload facing all GICs is unsustainably high, and many staff who were interviewed felt that efforts should be made to delegate or share responsibility for services with other Boards.

(9) Sharing the responsibility across Health Boards

Individual GICs in Scotland have arisen over time in a bottom-up, organic way, often based on the passion of a clinician to start up a new service to support an under-served group. Over the initial years of service development, clinics had been able to manage patients effectively as there were lower levels of demand. This situation no longer pertains, however, as demand has risen. Some interviewees felt that having only four GICs to serve the whole of Scotland is not a sustainable model. It is seen as not fair to staff or Boards providing services, and not fair to patients who are experiencing long waits, especially those who cannot be seen locally. One person said,

“I’ve no doubt that this is critical healthcare for people who are a scapegoat group in society and it's so easy for many Health Boards to just keep their hands off and say no, it’s nothing to do with me. And I just feel like it's unacceptable to be able to opt out.”

Several interviewees felt that more NHS Health Boards should consider offering some gender identity healthcare services, even if this wasn’t on a full-clinic or specialist service basis. For instance, one interviewee said that, “I think there’s a lot of good competent clinicians out there. But people are fearful that gender identity is so different that they can’t do it. What rubbish …there are plenty of staff out there [who could help].”

One staff member thought that the current Boards delivering gender identity services could act as early adopters, supporting others to gradually take on the delivery of (some/appropriate) services over the longer term. However, interviewees also identified a strong barrier to the sharing of responsibility across NHS Scotland for gender identity services, which is a reluctance to take it on:

“I think that most Health Boards in my view will not touch transgender patients if they do not have to and if their hand isn't forced. And I can’t help but feel that there's been a lot of carrot and not enough stick really in terms of really forcing the hand of Health Boards to look after their own patients ... I think that people don’t see it as their fight. It’s not their area. It's not their concern. So they'd rather just leave it well alone.”

(10) Consistent structures and pathways

Interviewees regularly referred to the fact that all of the GICs are different, with various structures, processes, approaches and staff mixes in place. While there is great appreciation for supporting experimentation, pilots and trying out novel approaches to improve gender identity services in Scotland, there was also a desire for some commonality across clinics regarding pathways and key structures.

“My experience, just having chatted with different gender identity clinics across Scotland, is that we all work quite differently. And I think there’s something about there being a bit more uniformity and it being less of a sort of postcode lottery where, depending on where you live, you might get quite a different experience of the gender identity clinic. So yeah, I think more nationalised training would definitely help with that.”

Interviewees were looking forward to the release of the gender identity healthcare services standards by Healthcare Improvement Scotland (HIS) in 2024, in addition to the NES Knowledge and Skills Framework for gender identity healthcare. Overall, they felt that this would help to provide more uniformity in standards and training for gender identity service staff. There were also suggestions that there could be a consistent approach to developing the infrastructure around GICs, in terms of where they sat in Boards. One interviewee said that, “I would like to have gender identity health services [sit] under the same umbrella.”

(11) Collaboration and partnerships

There was a strong desire, expressed across the local health systems, for greater collaboration and partnerships with, especially, third sector organisations and primary care services (the latter is addressed in more detail below, in the section on Shared Care with GPs). GIC staff felt that third sector organisations, which supported trans and non-binary patients and their families, had a wealth of experience in offering social support to service users. They wanted more constructive and formalised partnerships for GICs to work more closely with third sector groups to provide more holistic, wrap-around care to people on waiting lists, and pre-service support to people who were questioning their gender identity and wanted to talk about it, but not yet at the stage of wanting to be assessed. However, some interviewees expressed reservations about whether the NHS, as a structure, was flexible enough to develop collaborative care partnerships with third sector organisations.

(12) Shared care agreements with GPs

Research participants identified the absence of Shared Care Agreements (SCA) between GICs and GPs as one of the greatest obstacles to the delivery of gender identity healthcare services in Scotland. In SCAs, the GIC works to support GPs and other medical practitioners to take responsibility in conducting safe prescribing and monitoring arrangements for service users. The data collected suggest that, for some GICs, patients are never taken off their lists and referred back to primary care, because GPs are reluctant to take over that care without specialist oversight. The number of patients being treated by GICs therefore increases over time, putting demand on staff resources, while service users are unable to return to primary care.

For their part, GPs have explained how they are similarly over-stretched and, for the most part, lacking in specialist knowledge and skills in transgender and non-binary care. One GP interviewee felt that “there’s a huge debate about who does what, and in general what happens is that General Practices default, but we felt it wasn’t necessarily work that GPs should do [as] some of the work we see as specialist work.” In particular, “some of the prescribing is complex and … there’s a role for the GP, but it requires a specialist”, while monitoring clinics should be better utilised, so that blood test results “went back to specialists” rather than to GPs, which would make the system more efficient. GPs also expressed concerns around the lack of awareness amongst the trans and non-binary community around potential risks of different aspects of gender care, for instance, how the risks of hormonal treatments often increase with age.

GIC staff have talked about a ‘postcode lottery’ when it comes to finding GPs who are happy to take on primary care for service users, such as prescriptions and injections. Similarly, as summarised by one third sector interviewee,

“There is a lot of resistance from some GPs to get involved. I think there’s a lot of training that can be done … Trans people would really like to see more [treatment] pulled down into primary care because they see that as more sustainable.”

Both GIC staff and service users have expressed a strong desire for GP practices to play a bigger role in long-term maintenance treatment. A staff member from an organisation representing GPs also shared a view supporting the creation of SCAs, so that GPs had clarity around their role, and there was specialist oversight. Shared Care Agreements would (a) create more manageable workloads for GICs, which are currently providing specialist treatment alongside long-term primary care to service users, (b) empower GPs to support the non-specialised care of their patients in a more comprehensive way, (c) enable patients to be seen by their GPs for prescriptions and other long-term maintenance treatment, by someone they know, in a local practice so they don’t have to travel (in some cases a long distance) to the GIC, and (d) help ‘normalise’ the long-term care of service users. The latter point has been raised by several groups supporting service users, who feel that shared care “is the only sustainable solution really for long-term care.”

Some interviewees highlighted the difficulty in creating SCAs in certain areas. As one interviewee stated, “I think that it’s been very complicated because of GP contracts and the independence of GPs … and interestingly it is Grampian and Highland [where GPs] have both been historically not interested in prescribing, although you get the odd ones here and there. So there is something around that.” However, there is an awareness that SCAs have been effectively implemented in England.^[115]

The Lothian Gender Identity Clinic has recently put in place SCAs with local GPs “to support prescribing and blood screening (with GIC interpreting the results).”^[116] This development has been watched closely by Highland GIC, with whom Lothian has agreed to share its SCA template. GIC staff are looking forward to ‘Highlandising’ the SCA and hope that local GPs will respond positively. This is also likely to be of interest to other GICs. However, it will be important to ensure that GPs are adequately resourced to undertake Shared Care Agreements with GICs. As one interviewee said, the SG “will fund specialist care, [but] it's reduced its funding to General Practice. We have one of the lowest spends on General Practice in Britain and it’s been falling.” They confirmed that GPs had not received an allocation from SG funding to improve gender identity care. In addition to providing adequate resource to GPs for undertaking additional work and training around gender identity healthcare, it was felt that IT systems could be improved so that blood tests could be returned to specialists (for instance, in GICs) requesting these, rather than to GPs. Finally, one research participant thought that it may be helpful to have “someone more operational working directly with the Scottish Government” to advance SCAs across Scotland, and “agreed levers to make this happen”, for example, resourced means of local delivery, every Board to have SCAs and/or enhanced services, and blood monitoring clinics.

(13) NHS Health Board leadership and support

Interviewees emphasised how important it was to get support from Health Boards to take responsibility for gender identity services and put the necessary infrastructure in place to create sustainable services. One interviewee felt that there was a “shared challenge of just trying to increase the visibility of the service because it's a new service and also it's a very small service catering to quite a small number of people.”

There were some suggestions as to how NHS Health Boards could better support gender identity services. The first was ensuring that there was long-term core funding in place to maintain the viability of the service. The second was putting in place the necessary infrastructure and management structures, and clear lines of reporting and accountability, so that GICs are fully embedded in Boards. A third was setting internal KPIs and creating data to measure progress such as performance data and patient feedback data, to support continuous improvement. These building blocks could then raise the visibility of the gender identity service in quantifiable ways, putting it on a par with other NHS services that are being delivered.

In addition, some interviewees talked about the importance of having an advocate or ‘ambassador’ at Board level for the GIC, who could ensure it wouldn’t be overlooked in planning and prioritising resources, data development and staff support. One interviewee recounted a pivotal moment in the long-term development of a GIC, when a key person at a senior NHS level decided to actively support the service: “She came in and was like, well, there isn't any clinical governance ... So she made it her business to speak to people about it … in positions of responsibility.”

Finally, some interviewees felt that there may be opportunities for key individuals at the Board level to meet with others in the same position from across Scotland, to enable knowledge exchange and learning at the Board level to support strategic development, and to complement knowledge exchange at the clinic level to support operational best practice. One interviewee said, “I haven't had conversations with other Boards about this particular service, but that might be something worthwhile to do.”

9.3 At the national level

What changes can be implemented at the national (Scottish) level, to ensure that staff and decision-makers at the local and regional levels have the resources, frameworks, training, coordination and standards they need?

(14) Long-term core funding

A repeated theme to emerge across the case studies was the difficulties staff felt they encountered because of the inadequate and often temporary nature of the funding they received. One consequence of this is high levels of precarity felt by GIC staff: “We're just so tiny, which is fine, but it’s having a guarantee of funding ... no one can be permanent staff really because I might not get funding for one year.” This in turn exacerbates the difficulties faced by GICs in retaining staff, who may be inclined to seek opportunities with greater job security elsewhere in the health service. Loss of staff entails a loss of experience and knowledge with regards to gender identity healthcare, which may have been built up over years. This is particularly problematic considering the aforementioned dearth of individuals with existing experience and expertise around gender identity healthcare in Scotland. One interview said, “even just for the retainment of staff, I think it’s important for that funding to be consistent.”

Similarly, when GICs are only able to advertise for fixed-term rather than permanent posts, this can affect the number of appropriately skilled and experienced candidates they are able to attract, as evidenced by the difficulties experienced by some GICs in recruiting new staff in recent years. This can in turn impact business continuity.

“It’s always a bit of a challenge operationally when it's just annual funding, because you can't just recruit fixed-term staff, especially in hard-to-recruit to roles. So when you're recruiting permanent staff, but you've only got funding for a year and hoping that becomes recurring, but it's not confirmed, there is a bit of an organisational risk to that.”

Looking beyond 2024-25, there currently remains uncertainty, at the time of writing, over the future of funding for gender identity services in Scotland. This raises the prospect of GICs losing expertise and experience if staff seek greater job security elsewhere or if funding is not continued at a sufficient level to allow for the continued provision of services. Both eventualities would likely have detrimental impacts with regards to skills development and service delivery. In the short-term, some interviewees felt these risks could be ameliorated by the SG providing another tranche of improvement funding to GICs on a multi-year basis, to provide some certainty and security for staff and services. Beyond this, however, many interviewees felt that the resourcing of GICs should be the responsibility of the NHS rather than the SG. In short, there was a strong feeling that GIC funding should be normalised within the NHS, and it should become part of core funding, ear-marked for gender identity services.

(15) Clinical governance

Clinical governance is already a key priority of the SG Gender Identity Services Strategic Action Framework. Throughout this evaluation, participants repeatedly stressed the importance of developing clear clinical governance, standards and protocols to improve services. Staff who were interviewed prior to the publication of the HIS national standards and NES knowledge and skills framework were greatly looking forward to having clear standards and guidance to follow. Beyond this, some interviewees felt that greater effort should be made to find a professional medical ‘home’ for gender identity services, for instance in the way of having a professional college providing guidance, training and protocols. While some staff have spoken positively about the British Association of Gender Identity Specialists and the resources they provide, others feel that gender identity services should be integrated into, and regulated by, a pre-existing recognised professional medical body.

This links back to how some staff felt that there should be more consistent structures around GICs across Scotland, raising the question of where the best home for gender identity services is, be it Psychology, Sexual Health or Endocrinology (which is the case in some other countries). One challenge is that services operate across multiple disciplines, requiring input from them all; however, it also means that it’s easier to avoid taking responsibility for services as there is (as yet) no professionally agreed home. Therefore, some interviewees felt that discussions within NHS Scotland, involving representatives from key existing professional associations such as the Royal College of Physician, the British Psychology Society, the Society for Endocrinology and the Royal College of General Practitioners would be beneficial.

(16) Staff training and education

Improved national resources, opportunities and curricula in relation to staff training and education also emerged as an area that could have a significant positive impact for staff and decision-makers in gender identity services. GIC staff were pleased about the development of a Transgender Care Knowledge and Skills Framework (which was published by NES in September 2024). One interviewee hoped that the Framework would include, “some sort of training at different levels. So maybe people who aren't working directly with gender dysphoria but have clients who may be trans or maybe presenting with gender dysphoria - for them to have at least some of that knowledge and understanding so they can work appropriately with clients.” The published Framework does have four levels of skills to support staff with varying levels of experience in the area of gender identity healthcare.

Beyond this, interviewees gave some ideas to improve learning, including bringing more higher education input into training programmes, the sharing of research, and inviting in expert speakers to share best practice and international case studies - as well as mainstreamed training for staff across relevant NHS teams and in GP practices (which is addressed by the Framework). Staff interviewees felt that the Knowledge and Skills Framework could help in promoting awareness and understanding of issues relating to gender identity healthcare more broadly. Interviewees cited positive experiences of their own in providing training and information of this kind to those who had previously lacked knowledge and familiarity in this area:

“When I was in [the GIC] some of the staff there did multiple training sessions to GPs and some of that was around the psychological side, some of it was around hormone prescriptions. But frankly a lot of it was just generally like “what is trans” in a very broad information-giving way. And we always had really positive feedback from that.”

Findings from our learning event also highlighted the need for ‘recognised accredited training for clinicians’, alongside the need for ‘experienced clinicians to supervise the training’. Finally, interviewees felt that greater awareness-raising would also have the benefit of helping to counteract some of the fear felt by other healthcare staff in relation to gender identity healthcare, which was felt to be particularly important within the context of the current media environment with regards to this area.

(17) National networks and policy learning

There was a strong sense, from across the interviews, that staff involved in delivering gender identity services would benefit from more opportunities to engage with other services across Scotland. Some informal linkages have blossomed between clinics, with staff sharing their time, advice and resources to support other GICs (e.g., referring to psychology/endocrinology in other Boards). This cross-clinic support has also enabled staff working in GICs to develop closer relationships, and on some occasions friendships, with people working in similar areas across Scotland. These relationships have enabled staff - who work in small teams in an area that is underdeveloped - to develop a sense of belonging and support.

Most staff were also aware that there had been efforts to create more formalised national networks for gender identity services in Scotland, to foster greater cross-clinic learning and information-sharing on gender identity healthcare. The National Gender Identity Clinical Network Scotland (NGICNS) was established in April 2014 to perform this role as a national network in this area, and to help implement the 2012 Gender Reassignment Protocol.^[117] It provides a range of resources for professional staff working in the area, GIC service users, as well as the public at large. These resources include online information about healthcare services, signposting to third sector organisations, and workshops and events for staff.

There were many positive comments from interviewees about the existence of the NGICNS, and the improvements this has led to in availability of data on referral numbers and waiting times. The network was also described as supporting a holistic and collaborative approach which acknowledges the role of third sector organisations, which was felt to be helpful. Opportunities to get together in person and share learning from across Scotland’s GICs were highlighted by interviewees as incredibly important for the development and improvement of services, as well as staff development. One interviewee said, “we have the development day coming up, that's amazing because we're all getting together to actually meet each other. We're so tiny. It’s only like a handful of us. So having that inclusion, lets you all access specialist training.”

The NGICNS has been led by key staff from Lothian GIC, who have developed significant experience in training, outreach and skills development. However, there has also been an awareness of the need for sharing responsibility across Boards for operating the network across Scotland. However, the work of the NGICNS was recently paused owing to staff shortages and interviewees felt that consideration should be given to how the NGICNS may be put on a more sustainable footing, how it should be resourced, and what its aims and functions were.

Beyond the NGICNS, some interviewees felt that gender identity services would benefit not only from cross-clinic learning, but from learning from what other countries are doing to support trans and non-binary patients. While the Cass Report and review of young people’s gender identity services in England was a topic of conversation, there was a desire to learn about best practice from other parts of the world. Some interviewees felt that GICs could - potentially through NGICNS - develop their international networks and policy learning from other countries, for instance through international organisations focused on transgender and non-binary healthcare. This would enable access to evidence on best practice from other places. For instance, Transgender Europe (TGEU) - an organisation focused on trans people in Europe and Central Asia - has conducted research on trans healthcare across the EU 27 Member States.^[118] This includes the development of a ‘Trans Health Map’ which represents the availability and accessibility of trans-specific healthcare in the EU.^[119] It has found that better access to care and shorter waiting times have been associated with fewer assessment bottlenecks created by centralised referral processes, a diversity of service points, multidisciplinary clinics, and community-led initiatives.”^[120] There are potentially lessons here that Scotland can learn from other countries in its service redesign.