Gender identity healthcare: evaluation of the impact of Scottish Government funding
This report presents findings of an independent evaluation into the impact of Scottish Government funding, as allocated to NHS Health Boards, to implement local work to improve access to, and delivery of, gender identity services. The evaluation covers period between December 2022 and August 2024.
10. Conclusion
This project has sought to evaluate the impact of Scottish Government (SG) improvement funding on NHS Health Board’s efforts to improve access to, and delivery of, gender identity healthcare services. This involved a specific focus on how NHS Health Boards have used the SG funding to carry out their service improvement plans.
The project involved both a process evaluation (examining the impacts of the funding on service delivery) and an impact evaluation (examining impacts on outcomes for patient care). A wide range of methods were used to collect data for this study, including 45 interviews with clinicians, service managers, Board executives, third sector organisations and service users; two surveys with third sector organisations and service users (with 5 and 74 responses, respectively); questionnaires with GIC staff; a learning event with NHS staff delivering gender identity services (with 16 attendees); and a review of primary and secondary documents on gender identity services.
The project has found that the SG funding has had a positive impact on service delivery and patient outcomes in some places. For some gender identity clinics (GICs), SG improvement funding resulted in the hiring of new staff, the creation or expansion of Multidisciplinary Teams, improvements in communications with patients, new resources and processes to support people who were on waiting lists, clearer care pathways, and greater collaboration with third sector organisations in providing wrap-around and peer support, which together have in some cases led to reduced waiting times. Indirectly, some clinics have also reported better relationships with Health Board executives, with more clarity around governance and structures, as a result of the SG funding.
However, wider systemic issues have created challenges for GICs to use the funding effectively. All clinics experienced challenges in hiring staff, leaving clinics with limited capacity to support patients. Interviewees felt that this was a result of (i) the dearth of specialists working in this area; (ii) fixed-term contracts, which were insufficient to attract high-calibre staff who were looking for permanent posts; (iii) adverse political and media attention, which was seen to dissuade staff from working in GICs. Linked to this were challenges around training and education. All staff interviewed felt there was insufficient training in gender identity healthcare, not just for specialists in GICs, but also for wider healthcare professionals such as GPs. This meant there were small numbers of people trained to support patients who faced overwhelming demand.
The report identified 17 best practice learnings from the comparative case study analysis. These include practices that can be embedded at a local (clinic) level, such as fostering a cohesive team with the right mix of skills, appropriate grading and staff wellbeing support, and strong communications with patients; at the regional (Board) level, sharing responsibility for delivering services, with appropriate workloads and consistent structures and care pathways, including greater collaboration with the third sector; and at the national level, ensuring sustainable core funding for services, with clear clinical governance, national standards, training and skills development frameworks, shared care agreements with GPs, and strong networks to enable cross-clinic and cross-country learning. These learnings were identified to support Health Boards to continue to improve services.