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

4b. NHS Greater Glasgow and Clyde - Young People’s Service

4b.1 Overview and Development of the Clinic

As highlighted in the previous chapter, NHSGGC operates both an Adult Service and a Young People’s (YP) service. This chapter is a case study on the YP service at Sandyford. Whilst not as in depth as the previous chapter, which provides an overview of the Sandyford GIC as a whole as well as a focus on Adult Services, this chapter does provide an overview of the impact of SG funding on access to, and delivery of, the YP gender service at Sandyford. In particular, it analyses changes in the delivery of the YP gender service and changes to patient outcomes (including waiting times) since receiving the SG improvement funding. This involves an examination of service delivery, partnerships, training, staff development and patient outcomes. The final sections focus on issues that have enabled or inhibited changes to services.

The Sandyford YP service developed in response to an increase in need from children, young people and their parents. According to former Cabinet Secretary for Health and Social Care, Humza Yousaf, the YP service provision emerged “in response to need in Scotland and a recognition of a requirement to provide specialist care for children and young people presenting with potentially complex needs.”^[61] It is currently the only YP service in Scotland and is therefore open to referrals from across Scotland.

The YP service is currently staffed by the following permanent post-holders (which, put together, total the whole time equivalent - WTE - of 4.2^[62]):

• Medicine: 0.4 WTE (one post holder)
• Psychology: 1.6 WTE (three post holders)
• Counselling: 1 WTE (two post holders)
• Occupational Therapy: 0.2 WTE (one post holder)
• Medical Secretary: 1 WTE (one post holder)

In addition, the YP service shares the following supplementary temporary staff with the adult service, which have been created with SG funding (totalling 5.5 WTE):

• Medicine: 0.5 WTE (one post holder working primarily in Adult service)
• Pharmacy: 1 WTE (one post holder working primarily in Adult service)
• Psychology Assistant: 2 WTE (two post holders, primarily in the YP service)
• Operational Manager: 1 WTE (1 post holder working across both services)
• Waiting List Coordinator: 1 WTE (1 post holder working across both services)

4b.2 Scottish Government Funding Proposal

As highlighted in the previous chapter, the NHSGGC proposal for SG improvement funding covered both the Adult and Young People’s service at Sandyford GIC. Please see chapter 4a for details of the NHSGGC funding proposal. NHSGGC was allocated £496,500 in December 2022 to support gender identity services improvement work for both the YP service and adult service in 2022-23; it received £400,000 to support work in 2023-24; and it received £400,000 in 2024-25. The total funding allocation for NHSGGC for the three-year period of funding 2022-25 was therefore £1,296,500.^[63]

Given the growth of demand for the YP service, NHSGGC stated that funding would be used to improve waitlists and staffing models, allowing improved access and time for service planning “to look at a new strategy for service delivery and access to longer term investment.”^[64] A priority for the YP service was to maintain a Consultant Psychologist position during a period of parental leave, which was achieved through a maternity-leave secondment, and the provision of additional psychology resource. When planning for the recruitment of new staff, the proposal outlined that “we would seek to recruit imminently. It will likely be September/October at the earliest before staff could be in post.” The GIC also sought confirmation of funding for temporary posts beyond the initial 12-month period, to make posts more attractive.

4b.4 Services being delivered

According to staff members at Sandyford, young people referred to the clinic go through paediatric care for medical intervention. Previously, if they were not placed on puberty blockers (which has been paused since April 2024 following the Cass Review), they would have had meetings with psychiatrists and medical doctors for hormones after the age of 16. The care pathway for a young person is as follows:

• until August 2024, young people were able to self-refer. From August 2024, a referral from a clinician such as a GP is required for new patients
• a clinical psychologist then undertakes an initial assessment. According to a member of staff at Sandyford YP service, this will generally take place over 6-8 appointments, with roughly four weeks between appointments. The reasoning for having such an extended assessment period is to ensure that someone’s gender incongruence is “consistent and persistent.”
• as a result, Sandyford YP service provides a thorough and holistic assessment. They undertake a mental health assessment, also looking for possible signs or symptoms of neurodivergence, and they conduct an assessment of the person’s physical health. This helps them think about, for instance in exploring body image, the task of differential diagnosis - such as, whether gender dysphoria is present as opposed to a broader body dysmorphia
• following an assessment, the YP service then makes contact with individuals who know the young person, such as parents, families, schools or colleges, to enable them to complete a full developmental history
• this developmental history, plus the 6-8 assessment appointments, is used to build up a diagnosis of gender incongruence
• working with third sector organisations, the GIC would then signpost the young person and their family to LGBT Youth if they felt their services would be helpful and/or offer a range of complementary services. The service might also signpost on to CAMHS if there's a mental health difficulty that needs to be addressed
• prior to the Cass Review, the GIC would then refer patients on to endocrinology for a pubertal staging assessment. However, in light of the review, there has been a pause on puberty blockers and the GIC website stated, “Referrals from the Sandyford Sexual Health Services to Paediatric Endocrinology for the prescription of Puberty Suppressing Hormones have been paused for any new patients assessed by our Young People’s Gender Service.” ^[65]
• those young people currently receiving puberty blockers (who began treatment prior to the decision to pause puberty-suppressing hormones in April 2024) then have clinical psychology reviews every three months, as well as reviews from endocrinology, and typically receive their puberty blockers in either the Queen Elizabeth Hospital in Glasgow, or the Royal Hospital for Children and Young People in Edinburgh (given every 12 weeks)
• the purpose of a 3-monthly clinical psychology review is to check gender identity incongruency consistency, conduct mental health reviews, and assess how patients feel on puberty blockers. Endocrinology staff also conduct reviews on blood monitoring, bone health monitoring and physical health

Speaking to the process within the young people’s service, a member of staff described it as a “completely different ball game.” Diverging from the adult service, staff working in the YP service also have to take into account the patient’s developmental stage, their capacity to make decisions, and “any other coexisting developmental conditions that may present themselves in a young person - identity development at the core of the developing child, and peer relationships crucial at this age too.”

4b.5 Partnerships working and cross clinic links

As highlighted in the previous chapter, system relationships mapping was conducted, and can be found in chapter 4a. In relation to the YP service specifically, what emerged was not just the cross-clinic links, both within and outside of NHSGGC, but also wider partner relationships with third sector organisations. Notably, the young people’s service has established links with LEAP Sports and LGBT Youth Scotland.

The YP service has a relationship (although no formal link) with CAMHS, through referrals. However, the communication in this relationship sometimes breaks down, according to staff, when gender incongruence is mentioned. According to staff, oftentimes CAMHS suggest the patient experiencing gender incongruence no longer falls under their remit of care, regardless of any mental health concerns that need addressing. The service also has relationships with the Paediatrics Endocrinology teams at both the Royal Hospital for Children in Glasgow (NHSGGC) and the Royal Hospital for Children and Young People in Edinburgh (NHS Lothian).

Sandyford GIC has also purchased complementary services from their third sector partners. These are not part of a clinical pathway, and the GIC takes full responsibility for the clinical gender healthcare of its patients. At the same time, the GIC appreciates that there is a duty of care to offer broader support outside of any clinical interventions. Sandyford’s relationship with other organisations was commented on during interviews. “We have an agreement in place with LGBT Youth that if we get permission from the young person to pass details on to them, they'll get in touch and ... let them know what they have to offer. So, it's really about making sure they're on the right waiting list.”

A representative from LGBT Youth highlighted that these links, whilst not a formalised referral pathway, have contributed to young people seeking support when required:

“What has been happening is that with the clinical validation, particularly for the young person’s service at Sandyford, the young people are being given information about us and they are coming through. It’s not a formal referral. Young people get information and they choose if they want to get in touch, but they are doing that.”

Staff working within the YP service also highlighted their place within the wider care provision for children and young people: “It's not a mental health service … if we're concerned about a young person's mental health, we’re referring on to CAMHS.”

4b.6 Impact of Scottish Government Funding

Sandyford GIC staff are in the process of undertaking the clinical validation of the waiting list for the young people’s service, and have completed the administrative validation of the lists, which they attribute to the receipt of SG funding. This process of validating the waiting lists for young people has meant that,

“everyone in the list was contacted to check basic information that we had was correct; contact details were up to date. And at that point we asked them to get back in touch with us to confirm and if we hadn't heard from them – we would assume they maybe didn’t want the service and would be removed. We actually removed nearly 200 young people just through the admin validation.”

By doing this, the YP service has been able to build up a “really clear picture of the people that are waiting to be seen.” Not only has this new validation process enhanced the pre-assessment picture of patients, it has also had a direct and positive impact on patients themselves. “Pretty much every call I’ve listened to or completed myself, [patients have] said thank you so much for phoning,” a staff member commented.

“When you don’t hear for so long and you worry you’ve been forgotten or you’ve been missed…to have that contact with the service, it’s reduced anxiety. They feel, all right, I am on a list. They know about me. I'm not going to get lost. And it's a chance just to speak to someone as well. So we've had lots of positive feedback about it.”

Staff interviewed shared that, in addition to the SG funding providing staff with the capacity to contact patients on the waiting list, it has also provided a space for staff to work with third sector organisations like LGBT Youth Scotland and LGBT Health and Wellbeing. “We’re able to reach out to people and [give] a bit more support and … whatever it is they are looking for … in relation to their gender identity.”

4b.7 Impacts of Funding on Patient Outcomes

Waiting Lists and Patient Numbers

Official statistics in development reported by PHS found that, as of 31 March 2024, there were 997 people waiting for an initial outpatient consultation at NHSGGC young people’s gender services. Of that number, 98 people (10%) had been waiting between 3-4 years and 20 people (2%) had been waiting between 4-5 years.^[66] The number of people waiting had decreased by 16% between 30 June 2023 and 31 March 2024, which is mainly attributable to the reduction in young people waiting between the end of Q2 and Q3 (from 1,253 to 997), when an administrative and clinical waiting list validation was undertaken.^[67] During 2023-24, PHS reports that NHSGGC YP services had received 365 referrals for outpatient appointments.

While not forming part of the official statistics in development, Sandyford GIC confirmed that there were a total of 945 individuals on the waiting list for the Young People’s Service as of 27 August 2024.^[68] In a questionnaire for this project, the GIC indicated that while waiting list numbers for the YP service had changed slightly due the administrative validation processes carried out by the GIC following receipt of SG funding, the increased rate of referrals to the service month-on-month meant it had not been possible to achieve a sustained reduction in the waiting list.^[69]

Service User Impacts

Due to the focus on adult service users and safeguarding constraints, young people currently accessing services were not interviewed or surveyed as part of this project. There were, however, some service users who commented on their past experiences in accessing treatment through the YP service. Service users discussed the impact of outside influences such as the Cass Report on their experiences within the clinics, especially regarding accessing treatment within the YP service:

“I almost feel like it was easier back then, but I suppose things were just less scrutinised. With the blockers, I only needed one assessment for it, and I'm fairly sure the process has changed now… When I went to get reviewed for the testosterone it was you had to have two reviews from two separate people … but I heard quite a few people say they only needed one [previously]. So yeah, I think things are just more thorough.”

A parent of a young person who has accessed gender identity services highlighted: “my child is 26 now. She was fourteen when she started engaging with Sandyford. So we're well through the process. But the big thing is the waiting lists and despite all the money that's been thrown at [it], Sandyford have not seemed to be able to address that and alleviate that… I’m saddened by the lack of progress, in fact, it’s going backwards.”

4b.8 Structural and systemic issues

The YP Gender Service based within Sandyford is unique, as it is the only service within Scotland that focuses solely on children and young people accessing gender identity healthcare. As such, it faces specific issues that are not present in other clinics

The most significant issue highlighted throughout interviews with staff members was the impact of the Cass Review and the subsequent SG report on implications of the Cass Report for Scotland, in their day-to-day operations. Staff discussed that there has been significant uncertainty in the period following the publication of the Cass Review:

“It’s a very busy service and there’s obviously been lots of changes recently following the Cass report being published for the young person’s service … I feel like there’s more uncertainty than certainty in this service.”

This uncertainty was echoed by one clinician who highlighted the “lack of evidence that clinicians are working with.” Further than this, was the potential impact of this uncertainty on patient and staff wellbeing, with one staff member suggesting “the anxiety thermometers are [at] quite a high level, especially with … the stuff that's come out of Cass.” The immediate impact of the Cass Review was the pausing of specific medical interventions for young people, which led to some significant changes. As one staff member reflected, “we obviously are still seeing young people on the waiting list, but now there is a pause with an indefinite time scale on any onward referral for any medical intervention…So that's changed really formally since April 2024.”

Outside of the Cass Report’s publication, the YP service at Sandyford was facing other changes. There had been a focus on the redesign of the YP gender service, as there has been until recently a lack of specific guidance on this aspect of service delivery. One staff member, who was interviewed prior to the publication of the Scottish CMO’s MDT team report on the implications for Scotland of Cass Review, felt that having clear guidance and structures for service delivery was crucial when considering the role of the GIC in providing a national service for young people:

“I don't think we could do that [service redesign] until we're clear nationally what the strategy is for a young person's service, because it's all changing. I mean … whether others like it or not, we can’t ignore what’s happening south of the border just because it’s not happening in Scotland. So I think we just need to be really aware of all of that.”

With the publication of the Scottish Government’s ‘Cass Review - Implications for Scotland’ report, the future redesign of the YP service has become clearer. The report has recommended that gender identity healthcare services for young people are “not provided in an adult sexual health setting (such as the Sandyford Clinic) but are provided within paediatric clinical settings as with other age-appropriate services for children and young people.” Furthermore, the report stated that “to ensure sustainable services, a distributed network or regional model - instead of one site - would be the appropriate delivery model.”^[70] This will result in significant changes to the design and delivery of YP services across Scotland in the future, and it will ultimately mean that the Sandyford GIC will no longer host the national YP service for Scotland.

Beyond issues of service restructuring and the movement of YP gender identity services from the Sexual Health Service at Sandyford to paediatric settings across Scotland, staff shared concerns around how young non-binary people could be best supported by gender identity services in Scotland. One staff member highlighted that the 2012 Gender Reassignment Protocol (which was revised in September 2024 and renamed the Gender Identity Healthcare Protocol) did not take into account the care of non-binary people, further complicating an uncertain service delivery model:

“...we’re following a 2012 protocol that doesn’t talk at all about non-binary people, which is actually becoming a much bigger proportion of our cases. And [there are] non binary people asking for hormones, but of course hormones are only either feminising or masculinising. So how does that fit for a person who identifies as non-binary?”

Another staff member suggested that due to the lack of guidance, care pathways - especially for non-conforming identities - have become more difficult to manage: “Over the last 10 years, obviously there's been a big increase in the number of people presenting [with] gender non-conforming identities … we’ve really struggled to think about how we deal with that in a fair way.” These concerns speak to findings in a report by LGBT Youth Scotland in 2018, which found that non-binary young people had the lowest rates of feeling supported at GICs amongst LGBT young people, and that they often misidentified themselves with a binary gender in order to access support.^[71]

In addressing these issues, the revised Gender Identity Healthcare Protocol, published in September 2024, is more inclusive of non-binary people and acknowledges that ‘every person’s circumstance, goals and priorities for accessing a GIC will be unique to them’, thereby taking a ‘person-centred and needs-led approach’.^[72]

Further issues discussed by staff at the YP service at Sandyford included the challenges associated with recruitment into the service. Whilst recruitment generally was highlighted as a challenge across all the GICs, Sandyford’s YP service has, in recent years, faced particularly significant recruitment challenges. Staff interviewees suggested that temporary contracts and the rolling nature of the current year-on-year funding had led to challenges around staffing the YP service:

“The secondments [are] a drop in the ocean. It’s not making a difference on a wider scale to the people waiting to be seen, because we’ve now got lots of good members of staff that are looking to go back to their substantive posts because the uncertainty in gender healthcare is there. People don't want to work in a service where there’s so much uncertainty and especially when they're not getting permanent contracts to do it.”

The negative media attention focused on Sandyford GIC, which included protests outside the building, was also linked by staff interviewees to the challenges associated with retention and recruitment, especially with regard to the YP service. As one staff member stated,

“It’s a toxic debate that really paralyses clinicians that are trying to do a good job … I know there’s a huge waiting list because we don't have the resources to see everyone. But the people we are seeing, I genuinely believe we're doing a really good job. We're providing a really high level of care and we’re getting good feedback from the people we are working with. And that is just not heard amongst all the criticism and controversy.”

4b.9 Conclusion

The Young People’s Service at the Sandyford GIC in NHSGGC has faced specific challenges in not only service delivery but also service design. As the only dedicated YP gender service serving the whole of Scotland, it has faced increasing demand for services, challenges of staff recruitment and retention, and negative publicity due to the polarisation of debates around gender services for young people. On top of this, the service has also been significantly affected by the publication of the Cass Review in NHS England, and the Scottish Government CMO’s response to that review with regard to implications for Scotland. Thus, while it is ‘business as usual’ for the Young People’s Service at the time of writing, Sandyford GIC is aware that transformative change is planned for the future, as Scotland prepares to move YP gender services from Sexual Health at Sandyford to a distributed model that is located in paediatric clinical settings.

Overall, the data gathered suggests that the YP service at Sandyford GIC has been able to make improvements in service delivery following receipt of SG funding. Staff interviews confirmed that the funding received from the SG has been used to increase staff capacity in the YP service, including a dedicated assistant psychologist provision (which will transfer to the Adult Service once tasks within the YP Service have been completed), which has led to an ongoing clinical validation exercise which staff report has been a positive step. The SG funding has also enabled staff at the Sandyford YP service to complete administrative validation of the waiting list and to develop a better understanding of the profile of demand and needs of patients. Furthermore, the SG funding has been used to deepen collaborations between the YP service and third sector organisations including LGBT Youth Scotland. These findings suggest that the SG funding has supported changes to meet the needs of patients (understanding patient need), changes to systems (validating waiting lists), and changes to the governance of systems (stronger relationships with third sector organisations).

However, as with the Sandyford Adult Service, the GIC has faced challenges in converting activities to outcomes for patients, notably in reducing waiting lists. GIC staff have suggested that the increased rate of referrals to the YP service month-on-month has meant that the GIC has not been able to achieve a sustained reduction in the waiting list. Increasing demand for services has been further compounded by difficulties in hiring new staff to tackle waiting lists, which some staff felt could be partly attributable to the negative media attention that the service received. This has meant that service improvements have not been fully felt by service users, who still face long waiting lists. Furthermore, whilst individuals currently accessing the YP service were not surveyed or interviewed for this project, third-sector organisations and adult service users with past experiences of the YP service did suggest that the Cass Report’s publication - and in particular, the subsequent pause on puberty suppressing hormones for young people - had created difficulties in accessing interventions. As with the Sandyford Adult services, intended outcomes may be achieved if best practice learnings are considered, including a focus on staff wellbeing and safety, continuous service improvement, strong communications with patients, clear care pathways, long-term core funding, staff training and education, and clinical governance structures.