Trans patients in certain regions are having their repeat prescriptions withdrawn and being left at risk of serious medical harm, following slipshod new policies rolled out by local NHS England authorities.
In the last two years, a number of Integrated Care Boards (ICBs) have instituted policies forbidding NHS GPs from maintaining shared care agreements with private specialists, effectively banning in certain regions one of the few accessible and timely ways of accessing hormone prescriptions available to trans adults. Although many ICBs’ policies share a title and most of their content, some allow shared care with private providers, while others forbid it – the difference seemingly coming down to minor differences in interpretation of NHS England policy about co-funding. In addition, we have found that in cases where shared care has been banned, NHS processes to catch and prevent unlawful discrimination have not been adequately followed. Opaque bureaucracy, media scaremongering, inadequate funding, and unprofessional conduct have come together to leave many trans people at risk of serious harm, and unable to even begin to find out who is responsible.
In December 2024, the Bureau of Investigative Journalism and the Independent reported on GPs halting prescriptions for trans patients, describing the experiences of Emily*, a trans woman who was informed by text that her GP practice were going to stop prescribing her HRT. A hormone prescription had allowed Emily’s life to feel ‘ordinary’, but it had been taken away with minimal explanation, and no regard for her health or wellbeing. Social media is now awash with similar stories of trans patients having existing shared care agreements terminated, or being told that there is no prospect of shared care with a private provider. We spoke to Will*, whose usually supportive doctor had told him that due to a new policy, he couldn’t be offered shared care. The impact has been huge – Will described being unable to leave the house because of the way he looked. These decisions can have drastic effects on people’s lives, but attempts at patient safeguarding have been minimal. New policies brought out by NHS bodies are usually supposed to be accompanied by Equality Impact Assessments – short questionnaires designed to make sure that the policy is not discriminatory, and that equality law is not being breached. In our survey of NHS shared care policies, we found Equality Impact Assessments missing, incomplete, and sometimes filled out with totally nonsensical answers. One went so far as to claim that banning shared care would actually benefit trans people, and every other protected group.
Shared Care
Accessing transition-related care was never easy. Even prior to the release of these policies, trans patients in England faced numerous, often arbitrary, barriers. Waiting lists and available services vary wildly by region. Some ICBs commission GPs to do routine blood tests and prescribing – most don’t. You might get lucky, and live in the catchment of a GP surgery where GPs have some freedom to prescribe hormones before you are seen by a Gender Identity Clinic – either through a shared care agreement, or a bridging prescription. Luckier still, you might find a GP who is willing to do so, working under a practice manager who allows such prescriptions. Or you might get rejected by your GP, stuck on a seven-year waiting list for a GIC, and then kicked off for failing to respond to a phonecall that never arrived, get re-referred, and finally after years discover that nobody will prescribe for you anyway. The care offered by the GICs looks nothing like international best practice – although British nationalism allows individuals to gloss this worrying discrepancy as evidence of superiority. Instead of responding to excessively waiting lists by allowing GPs to prescribe, as is common in many countries, NHS England has doubled down on prioritising control.1
In the face of this dangerous healthcare landscape, trans people and concerned doctors have created workarounds within NHS systems to keep the bare minimum of transition-related care going. Bridging prescriptions by GPs and endocrinologists were one such workaround. Another was shared care with a private provider. Under this model, the patient would pay out of pocket to see a ‘gender specialist’ and then an endocrinologist privately, and their NHS GP would then prescribe them hormones on the advice of these private providers through a shared care agreement. Monitoring would be handled by the endocrinologist, but the GP would initiate blood tests and sign off on the prescription. This kind of shared care allowed trans people to access healthcare spending hundreds, rather than thousands, of pounds – and waiting months, rather than years. It was unfair, and regrettable, but it was an amount of money that many of us could save, or crowdfund, or borrow. In an ideal world, or a functioning healthcare system, shared care with private providers wouldn’t have to exist – but it has been a lifeline for many trans people.
Shared care agreements are not uncontroversial, even outside of their relationship to trans healthcare. GPs’ labour in managing shared care is often unfunded, as it falls outside of the General Medical Services contract. Collective action by GPs in recent years has sometimes involved withdrawing from shared care agreements, sometimes including shared care agreements with NHS providers. While in theory shared care agreements can be arrived at with private providers across disciplines, in practice they are most commonly used for prescribing ADHD medication, and hormones for trans patients – two areas of medicine where the level of public need has vastly outstripped the existing infrastructure, where ongoing monitoring is beneficial, and where there is limited will to prescribe. Guidance on shared care often appears impersonal, and focused on logistical and economic, rather than medical matters – but it disproportionately affects kinds of prescribing that are widely misunderstood, and subject to ongoing media scaremongering. This is surely no coincidence. Addressing the labour issue directly would be difficult, especially in the current political climate. But banning shared care through a minor policy change is easy, and makes the problem go away. The only losers are many thousands of vulnerable patients.
ICBs
A feature of this recent rash of GPs cutting off trans patients’ access to hormone therapy has been a lack of transparency (or possibly understanding by clinicians and administrators) about what has driven these changes. Sasha Baker, reporting in Trans Safety Network, recently described the appalling state of ICB guidance for GPs regarding their responsibilities to trans patients, including policies from two ICBs which explicitly discourage shared care and bridging HRT prescriptions respectively. We can further report on another likely source of many of the cutoffs: new ICB policies on shared care.
Of the 42 ICBs in NHS England, we found four that held (new) policies which explicitly banned shared care, and six that discouraged but did not explicitly rule out shared care agreements with private providers, two of which included exhaustive conditions that seemed to reflect recent media discussions of Gender GP, both referring to paywalled guidance produced by the private Community Interest Company, Prescquipp. Most of these policies, whether they banned or permitted shared care, have the same name: ‘Defining the Boundaries’.2 In many cases, the difference between a trans patient being allowed to live in peace, or being taken off hormones by their GP, came down to a single sentence and a postcode.
NHS Bedfordshire, Luton and Milton Keynes, NHS Frimley, NHS Mid and South Essex, and NHS Cambridgeshire and Peterborough all have publicly-available ‘Defining the Boundaries’ policies, dated to 2024 or 2025, which explicitly ban shared care agreements with private providers. They are only marginally different to other ‘Defining the Boundaries’ ICB policies which do allow shared care – a single additional sentence changes everything: ‘Where a patient has self-referred to a private provider for treatment, GPs should not enter into shared care arrangements with a non-NHS funded provider specialist for these medicines, as this constitutes co-funding of a single episode of care which is not permitted.’ Many other ICB policies similarly ban co-funding (funding from the NHS and from a patient) being used across a single episode of care – but do not identify shared care agreements as incidents of co-funding. No explanation is given for this difference in interpretation, as each policy is authoritative in its own region.
Not every ‘Defining the Boundaries’ policy bans shared care, but many leave its status ambiguous. NHS Nottingham and Nottinghamshire, NHS Birmingham and Solihull, NHS Herefordshire and Worcestershire, and NHS Devon ICBs all hold policies which make no explicit mention of shared care with private providers for ongoing prescription and monitoring.3 These policies allow GPs to prescribe medicine on the advice of a private specialist, as long as the GP is willing to accept clinical responsibility for prescribing, and considers the prescription medically appropriate according to their clinical discretion, but leave the question of ongoing monitoring open.
Even in areas which explicitly allow shared care, it is far from guaranteed. Some ICBs have policies that permit shared care with private providers, but require a series of almost impossible conditions to be met.4 In the areas covered by NHS South East London and NHS Derby, the agreement has to be approved by not only the GP and the practice manager, but also by all the other clinicians working at the practice, who all must be willing to take on responsibility for prescribing.5 This gives every clinician at the practice an effective veto on any shared care agreement with a private provider. For trans adults living in areas of England where shared care is theoretically allowed, access to hormones is still dependent on finding a GP who understands the medical need, is willing to take on extra uncompensated work, and is not prevented from prescribing for trans patients by more specific guidance. There may be others, but the only ICB we could find that explicitly stated that there is GP-level funding in place for ongoing prescribing and monitoring of HRT for trans patients, regardless of whether the shared care agreement is with a private or NHS provider, was NHS Sussex.
Co-funding rules apply across the entirety of NHS England, but they have been interpreted radically differently in different ICBs, leading to serious consequences for trans patients. This process of interpretation has been totally opaque, and it has produced a labyrinth of a system. Received wisdom has for a long time been that if your GP won’t accept a shared care agreement, you should try other GPs in your area – this is no longer useful in some regions, and still applies in others. NHS policy has functioned to make moving house or changing GP surgery a potentially life-altering nightmare for trans people.
Equality Impact Assessments
The NHS believes itself to have procedural safeguards against policy decisions having a discriminatory impact against a protected group, regardless of intent. An Equality Impact Assessment aims to identify whether any groups protected under the Equality Act could be ‘disproportionately disadvantaged by a policy, practice, process or service (or a planned change)’. Gender reassignment is one of the protected characteristics – an adequately conducted EIA for a policy banning shared care with private providers would identify that this would disadvantage trans patients, who are disproportionately likely to be reliant on ongoing prescribing and monitoring through shared care.6 We have seen no such adequately conducted EIA.
The policies which explicitly ban shared care – leading to trans patients having their hormone prescriptions abruptly stopped – are all missing thoroughly completed Equality Impact Assessments7. NHS Cambridgeshire and Peterborough’s policy has a brief Equality Impact Assessment, which simply attempts to offload responsibility by claiming that any equality impacts are more to do with commissioning decisions, and therefore can’t be addressed by this policy. NHS Frimley ICB’s policy has no EIA at all. NHS Bedfordshire, Luton and Milton Keynes does – a column asks ‘Could the policy create a disadvantage for some groups in application or access?’ – the answer boxes are left blank. A second column asks ‘If Yes – are there any mechanisms already in place to mitigate the potential adverse impacts identified? If not, please detail additional actions that could help. If this is not possible, please explain why’. For every row, including gender reassignment, it just says ‘no’. NHS Mid and South Essex ICB’s policy also features an Equality Impact Assessment – with the same nonsensical answer copy-pasted after every question – totally failing to address what each question asks. In the NHS Mid and South Essex table that follows, the writer has ticked to say that the policy will have a positive impact on transgender people – and every other protected group:
‘What data / information have you used to assess how this policy might impact on protected groups?’”
“Mid and South Essex ICB is committed to promoting equality in all their responsibilities – as commissioner of services, as a provider of services, as a partner in the local economy and as an employer. This policy will contribute to ensuring that all users and potential users of services and employees are treated fairly and respectfully with regard to the protected characteristics of age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex and sexual orientation.”
“Who have you consulted with to assess possible impact on protected groups? If you have not consulted other people, please explain why?’”
“This policy will contribute to ensuring that all users and potential users of services and employees are treated fairly and respectfully with regard to the protected characteristics of age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex and sexual orientation.”
NHS Mid and South Essex, Equality Impact Assessment, Policy MSEICB 080
This is the best we’ve got – the same block of text, responding to two questions, neither of which it even remotely begins to answer.
Conclusion
It is not, and has never been, appropriate for a GP to attempt to unilaterally medically detransition a patient. To do so on the basis of a policy change is appalling. The justifications for these denials of care are often impenetrably complicated, and make it incredibly difficult for a person being subjected to them to name any individual as responsible. The same NHS leadership that is celebrating partnerships with private providers is creating a climate of fear for the trans people who currently rely on NHS prescriptions initiated by private providers. Policy changes of this type are dangerous, not least because they can put an official gloss on an unofficial prejudice. It is abundantly clear that the NHS’s safeguards against discrimination in policy-making are not currently fit for purpose. There are many justifications GPs in NHS England may use to refuse to treat trans patients, even in collaboration with a specialist team (whether NHS or private), and each one can be made to sound reasonable. We are subject to constant unpredictable threats, and blamed for not being reasonable enough in the face of them. Shared care with private providers is not a fair model for trans healthcare, but leaving patients with no care is far worse. The current system is farcical, negligent, and cruel, and it’s able to be so because there is almost no relationship between the experiences of trans people and the decisions made about our own bodies.
If you have had your access to hormones revoked due to an ICB policy, we urge you to make a formal complaint. This is not an alternative to pursuing other ways of accessing care, but applies pressure, which we need.
Including but not limited to parts of the US, Canada, Australia, Spain, and Aotearoa New Zealand.
Many of these policies appear to be based on the same central policy document, or on other ICB policies based on this document. We sent NHS Herefordshire and Worcestershire ICB a freedom of information request to ask if they could send us a digital copy of the NHS England national principles policy that their ‘Defining the Boundaries’ policy stated it was based on. We received this response:
“Unfortunately, no, this was the main reason for ICBs deciding to adopt the NHSE Principle Commissioning Policies locally. When we asked NHSE whether the policies remained active, the answer was a resounding yes, but they had archived the page and never confirmed whether they would (or had) relocated them.”
Not every ICB that dismisses shared care does so with a policy. Buckinghamshire, Oxfordshire and Berkshire ICB, in their guidance on prescribing for ADHD following private consultation, say that “BOB ICB has no local policy in place that allows shared care between non-NHS commissioned private providers and NHS prescribers”.
These two policies seem to have a different genealogy than the ‘Defining the Boundaries’ policies - both cite (publicly unavailable) guidance from PrescQIPP, a Community Interest Company that offers resources and training about prescribing to NHS clients.
The private provider in question must also be UK-based, CQC registered, and employing GMC-registered doctors – ruling out GenderGP and GenderCare.
This should also bring up the impact on the protected characteristic of disability, as ADHD medication is one of the other common use cases for shared care with a private provider.
A number of the policies which don’t explicitly ban shared care but discourage it also have inadequate or missing EIAs.