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NEW: Tavistock’s Gender Identity Development Service rated ‘inadequate’ by CQC after inspecting GIDS in autumn. CQC say inspection prompted by concerns reported by healthcare professionals & Children’s Commissioner, who’d been given evidence by me&@deb_cohen for @BBCNewsnight. 1/
This is a long thread. Bear with it if you can. Inadequate is the CQC’s lowest safety rating. This means that a service is ‘performing badly.’ GIDS’ smaller clinic based in Leeds was also rated inadequate. GIDS had been rated good at its previous CQC inspection in 2016. 2/
Since then, concerns have been raised about the service: @BBCNewsnight revealed how some GIDS staff had raised serious concerns about safeguarding, the speed of assessments, and whether patients’ other difficulties were always adequately explored. http://tinyurl.com/y7frzsr6 3/
We read scores of pages of transcripts of interviews undertaken as part of an official internal review into GIDS, which also described how some staff felt they had been ‘shut down. We informed the CQC and passed on some details to the Children’s Commissioner for England. 4/
Full film here:
The CQC found a number of areas of weakness, rating GIDS ‘inadequate’ for being well-led and responsive to patient’s needs, and requiring improvement for being safe and effective. GIDS was rated ‘good’ for being caring. 6/
"When inspectors visited the Tavistock and Portman NHS Foundation Trust GIDS in October, we identified significant concerns,” Kevin Cleary, CQC's Deputy Chief Inspector of Hospitals, said. Let’s look in more detail... 7/
‘Is the service safe?’ Rating = requires improvement. “The number of young people on the caseload of the teams, and of individual members of staff, was high and varied considerably between different members of staff, causing caseloads to be stressful and difficult to manage.” 8/
10 staff members had caseloads of less than 10 young people, but one member of staff had a caseload of over 100. The overall average was 45, which increased to 52.5 when staff with caseloads under ten were removed. 9/
Staff at GIDS were found to “not always manage risk well”, with many young people receiving care or on the waiting list being vulnerable and at risk of self-harm. The CQC reviewed 29 care records: “the recording of risk and of plans to manage these risks varied considerably.” 10/
While some records demonstrated good practice, others had ‘limited information.’ Eg “one record had very little information about risks, despite the referral letter stating that the young person had frequent suicidal thoughts and had previously harmed themselves by cutting.” 11/
The report highlights how vulnerable some patients were, including: “young people who had made suicide attempts, young people who were vulnerable to sexual exploitation and young people who had a history of inappropriate or high-risk sexual behaviour.” 12/
‘Is the service effective?’ Rating = Requires Improvement. “Staff’s assessments of patients were unstructured, inconsistent and poorly recorded, “ the CQC said. "it was not possible to clearly understand from the records why these [clinical] decisions had been made.” 13/
The CQC reviewed 35 care records: “There was no clear rationale for clinical decision making.” The report notes wide variation in practice and in length of assessment, yet the Tavistock hadn't tried to understand why this was. 14/
Assessments had “no standard questions for staff to explore with young people…Whilst the criteria for considering referring young people for administration of hormone blockers was set out in the service specification, we saw no reference to this on any patient records.” 15/
The CQC said that the care records, “were not completed in a consistent or structured manner. This meant that many records did not demonstrate good practice. 16/
The report highlights the high % of GIDS patients with autism spectrum disorders. 28% young people assessed were referred for medical treatment. But, “records showed that the service may not have fully investigated or considered the needs" of autistic patients. 17/
While GIDS didn't record how many patients had diagnosis/suspected ASD diagnosis, in a sample of 22 records, more than half referred to ASD or ADHD. "Records did not demonstrate consideration of the relationship between autistic spectrum disorder and gender dysphoria.” 18/
The CQC says that while “Staff were experienced and qualified and had the right skills and knowledge to meet the primary needs of the patient group,” they “did not necessarily have the skills or experience to meet the needs of young people with complex needs.” 19/
The process for gaining consent to treatment & assessing capacity is also criticised. “The records of young people who began medical treatment before January 2020 did not include a record of their capacity, competency and consent,” the report says. It had improved since then 20/
“Staff’s approach to enabling young people to make their own decisions was unstructured and inconsistent although there was some evidence of good practice," the inspectors note. 21/
“However, whilst staff demonstrated their work on helping young people to understand information about treatment, there were very few details on the records of staff engaging in the more difficult task of supporting young people weigh-up the foreseeable risks and consequences”22/
GIDS carried out audits of compliance with their procedure for consent and capacity in March and September 2020. The March audit reviewed 10 records of young people referred for hormone blockers: “only three contained a completed consent form and checklist for referral.” 23/
CQC: “we found no evidence that staff had completed an assessment after the documentation was found to be missing...this meant that staff had still not assessed the capacity and competency of young people receiving treatment, despite being aware that they had not done so.” 24/
The September audit showed improvement, and found that only three out of 29 referrals to endocrinology did not have a complete set of referral documents. 25/
‘Is the service responsive?’ Rating = Inadequate. The CQC noted that over 4,600 young people were on the GIDS waiting list, with some waiting over two years for their first appointment. The regulator insisted waiting times and the service provided overall must improve. 26/
GIDS has a target waiting time of 18 weeks, but “out of 1089 patients being seen by the service, only 13% were seen within 18 weeks. In total 64% of patients waited more than 66 weeks to be seen, including 26% who waited two or more years.” 27/
‘Is the service well-led?’ Rating = Inadequate. “The service was not consistently well-led,” the CQC said. “Staff did not always feel respected, supported and valued. Some said they felt unable to raise concerns without fear of retribution.” 28/
Staff were positive & proud about working at GIDS and many loved their work. But some said "high caseloads and constant external scrutiny meant they worked under relentless pressure." While staff turnover was consistent with the ave for the trust, some still saw 24% as high 29/
The CQC raises the GIDS action plan from March '19 - the result of the Trust’s internal review. The CQC noted that while improvements had been made in some areas, “there were still many areas where improvements had not been consistent.” 30/
CQC notes there is still wide variation in practice with assessments ranging from “two or three sessions to over 25 sessions, with some young people receiving more than 50 sessions.” The CQC confirm staff reports seen by NN that some assessments consisted of two sessions. 31/
The CQC states: "Records of sessions with young people and their parents were often simply descriptions of discussions that had taken place. They did not include any analysis, structured assessment, professional curiosity or clinical decision making.” 32/
‘Is the service caring?’ Rating = Good. Despite criticism levelled above, staff were found to treat young people with ‘compassion and kindness.’ “They understood the individual needs of young people" & supported them "to understand & manage their care...” 33/
22 young people receiving care and treatment from GIDS were interviewed as well as the parents of 13 young people using the service. “Feedback from these people was overwhelmingly positive.” 34/
Responding to the CQC’s findings, a spokesperson for the Tavistock Trust said they took the report 'very seriously. “We agree with the CQC that the growth in referrals has exceeded the capacity of the service.” 35/
It apologised to patients and their families for the length of time they are waiting to be seen, and acknowledged the difficulty this caused. “We very much accept the need for improvements in our assessments, systems and processes,” they added. 36/
“We are determined to get this right for children and young people and will be agreeing a full action plan with the CQC to address further concerns.” 37/
The Trust said it would continue to support Dr Hilary Cass, who has been commissioned by NHS England to undertake an independent review of gender identity services for children and young people https://www.england.nhs.uk/2020/09/nhs-announces-independent-review-into-gender-identity-services-for-children-and-young-people/ 38/
A link to the full CQC will be posted once available. ENDS
