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

1. Background and Context

The Scottish Government (SG) has commissioned an independent evaluation of the impact of funding allocated to NHS Health Boards for gender identity healthcare services in Scotland. This evaluation is one of the commitments laid out in the NHS Gender Identity Services Strategic Action Framework 2022-24.^[1]

The overall aims of the Framework are to fund new service models, address waiting times, support those waiting to access services, and to drive long-term and sustainable service improvement for those accessing gender identity care. In December 2021, the SG committed to providing over £9 million in funding over a three-year period.^[2] In 2022-23 and 2023-24, the SG allocated £2.2 million of funding to territorial NHS Health Boards with GICs to improve access to, and delivery of, gender identity healthcare services, and a further £1.38 million was allocated in 2024-25. The total allocated to territorial Health Boards with GICs to improve gender identity services since December 2022 is thus £3.6 million at the time of publication.^[3] In April 2024, Minister for Public Health and Women’s Health Jenni Minto MSP extended the initial funding period from 3 years to 5 years, to include the period 2025-27. This was in response to feedback that challenges had prevented Health Boards from using all of the funding to date. The extension to the initial funding period was seen as a way to support long term sustainable funding.’^[4]

Gender identity healthcare services in Scotland have faced an increase in demand over the last few years, at a time of service review and redesign, a rise in demand and complex needs, changing approaches to gender dysphoria, and significant public interest. A review of the literature around gender identity healthcare can be found in Annex C. In summary, there has been an increase in the number of people identifying as trans and non-binary in Scotland over the past two decades. In 2001, a Scottish Needs Assessment Survey suggested that the trans population in Scotland was 0.005%, amounting to roughly 250 people.^[5] By 2022, Scotland’s Census found that 19,990 people in Scotland reported being trans or having a trans history, equating to 0.44% of the population aged 16 and over (with almost half identifying as non-binary).^[6]

However, while there has been an increase in the trans and non-binary population, evidence has suggested that gender identity services provisions are becoming overextended to accommodate growing numbers of people seeking care. A report by Scottish Trans (formerly the Scottish Transgender Alliance) in 2014 identified a number of barriers that patients experienced when trying to access gender identity services, including significant wait times from referral to initial consultation, insufficient clarity around treatment pathways, and accessibility issues due to long-distance travel.^[7]

The Scottish Public Health Network (SPHN) undertook a needs assessment of gender identity services in 2018.^[8] The report found that demand for gender identity services had been increasing in Scotland (as elsewhere), resulting in long waiting times; the average age at referral had fallen over time; and there were geographical inequalities in service access. Official statistics in development published by Public Health Scotland (PHS) found that, as of 31 March 2024, there were 5,640 people waiting to be seen by a GIC, comprising: 4,209 people waiting for up to 3 years; 618 people waiting between 3-4 years; 629 people waiting between 4-5 years; and 184 people waiting more than 5 years for a first outpatient consultation.^[9] The PHS report also found that during 2023-24, 40% of the total referrals for initial GIC consultations across Scotland came from 18 to 24 year olds, and 31% came from people below the age of 17.

Evidence from a 2022 Health Needs Assessment commissioned by NHS Greater Glasgow and Clyde (NHSGGC), NHS Lothian and PHS^[10] found that significant waitlists were impacting trans and non-binary people’s mental health. Lengthy waiting times were found to bring a continuation of gender dysphoria, that is, the psychological distress a person experiences due to incongruence between their gender identity and their assigned sex at birth.^[11] The evidence also highlighted high rates of anxiety, depression, suicidal ideation and attempts, and self-harm amongst patients on waitlists.^[12] However, a supplementary report commissioned by NHSGGC suggested that trans and non-binary people were not disclosing mental health issues to GIC staff, for fear that the information would result in their gender identity treatment being halted.^[13] This report also revealed that people on lengthy waiting lists were seeking gender identity healthcare outside of NHS Scotland, by seeking private treatment, purchasing hormones online to begin medicating, or travelling abroad for care. The NHSGGC supplementary report also revealed how staff in GICs felt overstretched due to patient demand exceeding their capacity, and the lack of specialists in gender dysphoria leading to recruitment issues, which had an impact on service delivery.

In light of such evidence, the SG has explored ways in which these issues can be remedied. In 2012, the SG introduced the Scottish Gender Reassignment Protocol (GRP), one of the first of its kind to standardise gender reassignment clinical pathways.^[14] This protocol was updated in September 2024 as the Gender Identity Healthcare Protocol.^[15] The SG also established the National Gender Identity Clinical Network for Scotland (NGICNS) in 2014, to support the implementation of the protocol.

In December 2021, as mentioned above, the SG released its Strategic Action Framework to improve NHS gender identity services from 2022 to 2024.^[16] The Framework sought to fund new service models, address waiting times, support those waiting to access services, drive service improvement, and support staff development. The Framework set out 17 commitments, including: the establishment of a National Gender Identity Healthcare Reference Group to oversee the implementation of commitments^[17], the review and updating of the Gender Reassignment Protocol^[18]; the development of national standards for adult and young people’s gender identity services^[19]; the development of a Transgender Care Knowledge and Skills Framework^[20]; and the development of robust waiting times data collection, monitoring and reporting.^[21]

Meanwhile, the research landscape around gender identity healthcare has continued to evolve. In April 2024, the Cass Review issued its final report on gender identity services for children and young people to NHS England.^[22] The review sought to understand why there had been a significant increase in the growth of referrals over the past 5-10 years and a change in the case mix of the young people seeking support. The review found that services were overwhelmed, leading to delays, and that young people received inadequate support. The Cass Review made recommendations to improve the clinical approach and service model to serve young people.

While the Cass Review was commissioned by NHS England and the recommendations are based on services in England, the SG considered how they may apply to Scotland.

In April 2024, a multidisciplinary team within the Chief Medical Officer’s (CMO) office, comprising paediatric, pharmacy and scientific expertise, was established to “assess the clinical recommendations and engage with the relevant clinical community and leadership in Health Boards in relation to those recommendations.”^[23] In July 2024, the CMO team published its report, recommending that puberty suppressing hormones be paused until further research was carried out, and that young people’s services should be developed and delivered on a regional basis in paediatric settings.^[24]

This evaluation project forms part of the SG’s Framework commitments to improve gender identity healthcare services. It focuses on the improvement plans implemented by territorial NHS Health Boards with GICs that have received SG funding for improvement work. It evaluates the impacts of SG funding to NHS boards on waiting times, access to services, support to those on waiting lists, service delivery, and overall quality of care provided by GICs. It includes a process evaluation, which examines the implementation and delivery of healthcare services by GICs as a result of the improvement funding, as well as a summative impact evaluation, focused on the effects of the funding on patient care. The aims are to explore how the funding for services has been delivered and impacts on patient care.