Since the Cass Review’s was published in April 2024, trans healthcare on the NHS has become significantly more precarious and unpredictable. While the dire situation for children has happened in the open – the puberty blocker ban made national headlines – the driving forces behind the erosion of adult care are more nebulous, and their effects distributed seemingly randomly.
On paper, little to nothing has changed. In practice, in the months following the publication of the Cass Review, many trans people went to reorder their repeat prescriptions for hormones, only to discover that their GP surgery was terminating the agreement that had enabled the prescription.
One potentially influential intervention was the release of new guidance from the Royal College of GPs in late April 2024. While noting that GP surgeries should work with Gender Identity Clinics in the same manner as any other specialist service, it also noted, “Given the significant existing workload challenges in general practice, the RCGP supports those who feel that issues of workload preclude them from sharing care.”
Many GP surgeries appear to have taken this as a licence to discriminate against trans patients. Examples of letters from GP surgeries that have taken the unilateral decision to stop prescribing HRT abound.
Whether driven primarily by transphobia, a desire to save money, or an unwillingness to incur the wrath of anti-trans bigots, the effect has been the same: trans people who had gone through the lengthy and humiliating process of obtaining a diagnosis of gender dysphoria on the NHS had the their access to hormones thrown into doubt – or in some cases terminated altogether.
The RCGPs appears to be aware of the harmful effects of its 2024 guidance, releasing overhauled recommendations in March 2025 This update emphasises that working with GICs is part of a GP’s “core role” in managing the healthcare of trans patients, and makes clear that “prescriptions should not be abruptly stopped” for patients taking cross-sex hormones.
It also recommends GPs refer to local advice when it comes to initiating hormone prescriptions for trans patients – which can mean very different things in different areas. Integrated Care Boards have a huge amount of influence over many people’s lives in England, making some areas of healthcare essentially a post code lottery.
ICBs set their own rules for when they will fund ADHD medication, fertility preservation, IVF and breast reductions, and make individual decisions about funding requests for rare conditions. They also provide guidance to local GPs.
However, their guidance about trans healthcare is often based on misunderstandings of how trans healthcare is commissioned. Gender Identity Clinics are staffed largely by psychologists and the system relies on GPs to take over prescribing, technically on a shared-care basis, but, in reality, almost always without ongoing specialist input from an endocrinologist. Prescribing and monitoring HRT for trans people isn’t complicated, but as GPs are not trained to do it, many say it is outside their competence.
Perhaps more importantly, under these arrangements, they take on legal responsibility for prescribing, which many are reluctant to do.
FOI requests to English Integrated Care Boards and Welsh University Health Boards reveal the wide variety of approaches to trans healthcare around the country, and may account for some of the inconsistency between different local areas – though in all cases individual surgeries have significant latitude.
‘Not my problem’
The majority of ICBs provide no specific funding to trans healthcare, and many said they had not issued any local advice to GPs about treating or registering trans patients since the Cass Review was released.
This is unsurprising as trans healthcare is centrally commissioned by NHS England, though responses to my FOI requests reveal problems with the commissioning model. Many ICBs told me to redirect questions about commissioning of trans healthcare to NHS England, even though a few others do commission local services.
Disturbingly, North Central London ICB and Birmingham and Solihull ICB told me to redirect questions about GP care, as well as commissioning, to NHS England. The suggestion that all trans healthcare is the purview of NHS England implies a severe lack of consideration for the needs of trans patients who are yet to be seen by a GIC or have been discharged, when they are likely to remain on HRT and in need of blood tests to monitor their hormone levels.
The existence of a national specialist service appears to act as an excuse for many local services to ignore the issue entirely, allowing patients to fall between the cracks of a broken system.
Meanwhile, Hampshire and Isle of Wight ICB only communicated with GPs to inform them about the puberty blocker ban, providing no information on the limited scope of this to ensure it does not have a chilling effect on trans healthcare more widely. Similarly, both Gloucestershire and South-East London ICBs communicated with GP surgeries only to tell them that in the wake of the Sullivan Review, they could no longer issue new NHS numbers to trans patients under 18
No ICB explicitly told GP surgeries they could cut off access to existing care for trans patients, or that they could refuse to register trans patients. However, some offered advice that appears intended to strongly discourage GPs from playing any role in trans healthcare.
Worst of the worst
NHS Frimley, which oversees local services for patients in parts of Berkshire, Hampshire, Surrey and Buckinghamshire, is a notable outlier, providing actively hostile guidance to GPs.
It goes beyond mentioning the need to safeguard young trans children, saying that “the young person’s gender identity may be consciously or unconsciously influenced and not necessarily the young person’s sense of self”.
It also repeatedly encourages GPs to inform the ICB, make safeguarding referrals and inform regulators if any trans person under 18 requests or admits to taking cross-sex hormones, placing them in the same category as puberty blockers, which have been banned.
When it comes to adult care, the guidance goes out of its way to provide a range of excuses to GPs under which they can refuse to provide it. It cautions against bridging prescriptions, saying they should only be considered if a patient is already self-medicating or likely to self-medicate, and at risk or self-harm or suicide, and the GP consults with a specialist.
This guidance is wrongly attributed to the GMC, though the RCGP makes the same error.
Frimley ICB is also at pains to discourage shared care agreements with private providers. It cautions against sharing care with any clinic not regulated by the Care Quality Commission, and then argues against Gender Plus, one of few CQC-regulated providers, saying its registration was “under legal challenge” (true at the time of the FOI) and suggesting that it is “primarily aimed at the 16-25 age group”, insinuating that people in this age group should be prevented from accessing transition care.
Even when it comes to NHS providers, Frimley ICB is at pains to remind GPs that they must be confident of the safety of the medication they are prescribing, and can end a shared care agreement with an NHS service if the service becomes insufficiently communicative. The issues raised by abruptly ending someone’s access to hormones are not mentioned at all.
The guidance ends with a template letter laying out suggested conditions to enter a shared care agreement with a private provider. The template says that it will only accept requests from CQC registered clinics, and that any specialist providers must have spent at least two years working for an NHS gender service. It asks the specialist prescriber to provide evidence of “participating in credible research relating to gender nonconformity and gender dysphoria”, and requires it to have a multidisciplinary team of gender specialists that meets regularly.
It unsurprisingly refuses to consider shared care with private providers for 16–17-year-olds, and – extremely disturbingly – infantilises 18–25-year-olds. For this group, which the letter says are “ at [sic] potentially vulnerable stage in their journey” ICB advises GPs to say: “We require evidence that there has been consideration given to reaching a point of maturity before taking a decision to transition and / or take hormone treatment, and has [sic] been offered and / or received holistic, therapeutic support, including addressing any comorbidity such as anxiety, depression or neurodiversity.”
It is clear the authors of this guidance have an agenda, and are going out of their way to prevent transition care being accessed. The requirement to assess “maturity” in legal adults is likely illegal, though very unlikely to be litigated.
Another ICB with guidance that goes beyond NHS England’s anti-trans position is Nottingham and Nottinghamshire, which strongly advises against HRT bridging prescriptions for suicidal trans patients, saying instead that “patient needs to be referred to Crisis team if thought to be high risk”. It goes on to recommend against providing bridging prescriptions to trans patients who are buying hormones from the internet, including if they are suicidal, unless a GIC recommends it.
A hopeful note
Frimley and Nottingham and Nottinghamshire are outliers. Most ICBs aren’t doing anything to make trans healthcare more accessible, but neither are they going out of their way to thwart it.
A few are even taking action to support trans patients. One of the most surprising responses to my FOI requests was from Somerset ICB, which is currently piloting an informed consent pathway, allowing trans patients to self-refer to a service (run by the WellBN GP practice in Brighton, which the ICB commissioned) that does not require a diagnosis of gender dysphoria to get HRT.
Patients need to read and understand the risks and side effects of HRT, as well as the changes that will occur, and then attend an appointment with a doctor which covers their physical and mental health. The appointment is also an opportunity to ask any questions they may have about the treatment; it is the kind of support trans people have been calling for.
While no other ICB seems willing to roll out trans healthcare on an informed-consent basis, several provide additional funding to GP surgeries willing to prescribe HRT to trans adults, and some say they have provided training on engaging respectfully with trans people.
Meanwhile Wales – which has University Health Boards (UHBs) instead of ICBs – has a gender service that appears more willing than many of those in England to work with GPs to ensure their patients get timely support, including providing advice on bridging prescriptions.
Though outside the scope of my investigation into commissioning of local services, TransPlus in London, and the Indigo Gender Service in Manchester have shorter waiting times than other NHS-England commissioned clinics. However, they do still assess and diagnose gender dysphoria, rather than offering trans healthcare purely on an informed consent basis.
The state of trans healthcare across England has undoubtedly worsened since the Cass Review, but while many ICBs have cracked down, others – like Somerset – show that it is absolutely possible for NHS services to do better by trans patients, even in a hostile regulatory climate.