The Gender Identity Development Service (GIDS) at the Tavistock and Portman NHS Foundation Trust carries out some of the most complex and contentious clinical work in the NHS. It deals with children and young people who are experiencing discomfort over their gender identity, but is it raising patient safety concerns?
Some of the children it sees go on to change their legal gender. Some receive physical treatment in the form of puberty-blocking medications. Some go on to have further treatments including cross-sex hormones and surgery.
The service, which is heavily over-subscribed, is a divisive one. A number say it offers vital, even life-changing care to children in great distress and need, others are less positive. The list of concerns raised about the work and processes of GIDS is quite long, and a number come from staff whistleblowers.
Some of these concerns include:
- The unexplained rapid rise in GIDS caseload and the fact that this caseload skews towards girls. The Government has commissioned research asking why almost three-quarters of new referrals to GIDS are female.
- The unknown long-term effects of the drugs used. The NHS recently changed its main online guidance about puberty blockers, while the use of blockers and cross-sex hormones is under review by NHS England.
- Staff and officials say the GIDS is doing things that are not always in the best interests of the children it treats.
That last point deserves expansion because there is a striking list of reports and incidents where people in and around the GIDS have raised worries about its work.
- Last year, Marcus Evans, a psychoanalyst and one of the governors of the Tavistock and Portman NHS Foundation Trust that runs the GIDS resigned over the management of the service
- In 2019, the Times reported five former GIDS staff had quit over worries about standards of evidence and care.
- In July 2019, Dr Kirsty Entwistle, a former GIDS clinician, wrote an open letter that described a service where vulnerable young people are potentially being pushed into serious, life-altering medical and social choices on the basis of dubious evidence, by staff either unwilling or unable to act with caution and care.
And last month – in a report which deserved more attention than it got – Newsnight revealed details of internal reviews at the Tavistock trust, suggesting that not only were some clinical staff worried about the way children are being treated at the GIDS, their concerns were not being properly addressed and, in some cases, staff were being actively discouraged from reporting such worries.
This last point is especially serious. For what I hope are obvious reasons, it is now widely acknowledged that it is very, very important that NHS bodies have both culture and procedures that encourage clinical staff to raise any concerns they have about patient safety and wellbeing.
Too many cases have seen systemic failures of care unaddressed because staff were not willing and able to raise concerns, leading to patients’ harm and sometimes death. Good whistleblowing policy and practice are fundamental to providing good, safe care.
Among the people at the Tavistock and Portman NHS Foundation Trust who are supposed to ensure such policy and practice are in place is Sonia Appleby, the ‘Named Professional for Safeguarding Children’. She describes her role in this way:
'My primary task is to ensure that clinicians protect their patients/service users from avoidable harm and are also able to recognize and appropriately respond to situations where under 18s are in need of safeguarding. My secondary task is challenge practices which are either harmful or could lead to harm.'
In other words, Appleby is part of the system at the Tavistock and Portman NHS Foundation Trust that is supposed to identify and address concerns from NHS staff who want to ‘blow the whistle’ on things that could be causing harm to the children seen at the GIDS.
Appleby is now taking legal action against the Tavistock and Portman NHS Foundation Trust. She says that when she raised the concerns of GIDS staff about patient safety to senior management, she was effectively punished. She also says that the Trust management actively discouraged clinical staff from raising patient safety concerns with her.
Appleby, who has been in legal dispute with her employers since November 2019, has now gone public with these concerns and set them out in a public appeal for funds to support her legal action. You can read the whole extraordinary document here. Appleby’s own account of her claim at the employment tribunal is this:
‘In my claim, I allege that because I made "protected disclosures" to my line manager regarding concerns raised by GIDS staff (that the health or safety of patients was being, had been or was likely to be endangered), I was subjected to detriments.
I allege these detriments are:
i) the Tavistock misused it's [sic] own procedures to besmirch me and therefore jeopardise the role of safeguarding within the Trust;
ii) there was an unwritten but mandated directive from the Tavistock management that safeguarding concerns should not be brought to my attention despite being the Trust Safeguarding Children Lead;
iii) and, clinicians were discouraged from reporting safeguarding concerns to me.’
She claims that this created a ‘dangerous’ situation for the children treated at the GIDS:
‘I maintain that there needs to be proper and effective safeguarding scrutiny of GIDS especially given the nature of its work, and to prove that some clinicians have been told by the GIDS Director not to seek safeguarding input from the Trust's Safeguarding Children Lead, which is dangerous, in terms of patient/service user safety and contributes to a detrimental, organisational culture to keep safeguarding concerns hidden from scrutiny.’
Not least because I am aware that the issues around gender-variant children are sensitive and complex, and because I think the gender debate needs careful discussion, I’m trying to offer little in the way of commentary.
Instead, I’ll try to offer this simple summary of the facts.
The senior NHS clinician, whose job is to ensure whistleblowers’ concerns about the safety of vulnerable children are heard and addressed, has herself blown the whistle on an NHS organisation which she says is actively discouraging staff from raising concerns about the safety of children.
As things stand, despite the growing number of concerns that are raised about their work and policies, there is no outside investigation of the GIDS and the Tavistock trust. The Care Quality Commission is due to carry out a routine inspection in the next year or so, but there is no other inquiry, either from NHS authorities or by the politicians who are ultimately responsible for ensuring that the NHS is helping patients, instead of harming them.
But when an independent inquiry does come, as it surely will, one of the questions that ministers and MPs will have to answer is why it took them so long to act.
P.S. I asked the Tavistock trust about Appleby’s claims. In a statement, the trust said:
‘The Tavistock and Portman NHS Foundation Trust strongly denies the allegations made by the claimant and will be robustly defending the matter through the employment tribunal process. Safeguarding is of the utmost importance to the Trust and this commitment is reflected in the practice of all our staff.
'In August 2018 a safeguarding lead was created specifically for GIDS to reflect the growth in the service. This role fits within the existing safeguarding pathway and procedures across the Trust and has been replicated in other services across the Trust. Safeguarding is further supported at Trust level by the Children’s Safeguarding Lead, Named Doctor, and Adult Safeguarding Lead, who all report to the Medical Director, the Board Executive Lead for Safeguarding.
'All named professionals have clear roles and have sufficient time and support to undertake them. Clinical scenarios including safeguarding issues that were raised during the GIDS review were fully explored and issues identified were further investigated and, where appropriate, addressed in the review’s recommendations.’