APPENDIX 1 SERVICE SPECIFICATION This Service Level Agreement relates to the provision of specialist Gender Identity outpatient services as defined in the following Operational Policy. The Provider will work with the patient’s home commissioner and GP to ensure a seamless transition of care for patients requiring Leuprorelin in line with the Operational Policy and the Shared Care Guidelines. The provision of surgical procedures is specifically excluded from this agreement. OPERATIONAL POLICY LEEDS GENDER IDENTITY SERVICE Outpatient Suite st 1 Floor Newsam Centre Seacroft Hospital York Road Leeds LS14 6WB 1. INTRODUCTION The Leeds Gender Identity Service (LGIDS) is a specialist tertiary service provided by Leeds Mental Health Trust’s Specialist Services Directorate, clinically managed through the Specialist Psychotherapy Service and delivered to Service Users within an Outpatient setting. The overall aim of this Service is to provide a realistic framework to assess, manage, diagnose and treat gender dysphoria via a professional therapeutic relationship and this Service’s policies, procedures and Standards of Care. The individual outcome from attending the LGIDS is to achieve as far as possible resolution of gender dysphoria and to help the individual work towards an integrated identity that has personal meaning. This, not gender reassignment through hormone treatment and/or surgery per se, is the central aim of this Service. However, for those wishing to change gender role the outcome is to have enabled the individual to achieve a degree of gender expression and appearance that facilitates a more comfortable lifestyle. This is a collaborative endeavour between the individual and the different clinicians working within a multidisciplinary team. The Pathway of Care is designed to be for a three-year period only (with an additional year post-operatively if appropriate). Any extension of the pathway within the Service will require negotiation with the local Primary Care Trust (PCT). 2. PATHWAY OF CARE (a) OVERVIEW Service User’s should be able to explore all possibilities for managing gender dysphoria & transsexualism and understand what entering a gender reassignment programme means. Service Users are helped by the members of the Gender Team to reach a satisfactory outcome, which may or may not include hormone reassignment therapy or surgery. Service User’s may leave the Service at anytime during the programme. If individuals attending the Gender Identity Service make a decision to access private treatment before a time that is felt appropriate i.e. not fulfilling the criteria based on the Harry Benjamin Standards of care, a decision may be made by the team inclusive of client’s views and following a CPA to discharge the individual from the Gender Identity Service. If an individual wishes to opt for private treatment at an appropriate time i.e. after fulfilling the standards of care patient choice will be respected and care within the service can continue if appropriate, the private treatment may include laser treatment, electrolysis, hormone and surgical interventions. Following assessment there are a number of options for the Service User: They may be discharged to more appropriate local services. They may enter the gender reassignment programme, this consists of : Counselling, education and support. Occupational Therapy if appropriate Speech and Language Therapy Endocrine reassignment treatment. Surgical reassignment (male to female) is provided by the University Hospitals of Leicester NHS Trust, and London University Trust (female to male). (The Service User may not require to use all aspects of the Service that are available.) The Leeds Gender Identity Service (LGIDS) is based at the Newsam Centre (Leeds Mental Health Trust) and co-ordinates the pathway of care that is best suited to meet the assessed needs of the individual negotiated on an ongoing basis. It will take place in an atmosphere of respect that aims to promote health and well-being. (b) REFERRAL As the LGIDS is a tertiary service, taking referrals from a wide area in the North of England, it can only accept referrals from secondary care, which have been assessed by the local sector consultant psychiatrist or the community mental health team working with the consultant. There must be agreement from an NHS local sector consultant psychiatrist to respond to concerns that may be raised by the LGIDS to ensure that support is mobilised locally should the need arise, including the management of enhanced levels of the care programme approach, therefore private psychiatric referrals are not sufficient. All community mental health team referrals must have the written support of the Service User’s G.P. before this Service can accept them this is to facilitate shared care of endocrine monitoring if required. This Service has an agreement with the West Yorkshire Primary Care Trusts to see twenty three new Service Users per year for treatment within this Service and also with the North Yorkshire, East Yorkshire & North Lincolnshire Primary Care Trusts to see eleven patients per year. Other referrals will be seen on a cost per case basis and G.P.’s will be asked to provide confirmation of support for funding from their local P.C.T. for all treatment, including surgery, at the time of referral. (The contracting department of LMHT will negotiate and confirm arrangements.) The service requires a GP referral not only as support for the client to access the service but also to show commitment to shared care arrangements for prescribing hormone treatment once a client is discharged from the Gender identity service. The individual must be over 17 years old. No further age limit is set. Referrals should be sent in writing from the local sector mental health team accompanied by a supporting letter from the G.P. Referrals should be addressed to: Leeds Gender Identity Service Outpatient Suite 1st Floor Newsam Centre Seacroft Hospital York Road LS14 6UH Tele: 0113 30 56346 Fax: 0113 3056483 The local sector mental health team’s referral letter should include an initial diagnosis, a full psychiatric history with an assessment of risk and identification of CPA status. The letter should also state that it has been discussed with the responsible consultant psychiatrist. The LGIDS only expects the sector psychiatrists to provide local psychiatric support if this becomes necessary during the gender reassignment programme of treatment and not on a regular basis, however the service would recommend that the local sector psychiatry team remain involved when the client has been referred from outside of the local area to provide local support when needed. The LGIDS expects the G.P. to be able to support this Service’s aims and philosophy so as to facilitate shared care. Referrals will be put on the waiting list only if these requirements are met. If it is decided that the referral is unsuitable for this Service then the referral will be returned to the referring agencies with a detailed letter of explanation. Monthly team meetings will take place to discuss new referrals. Referrals will be discussed to ascertain eligibility criteria. If a referral is accepted it will be allocated to a Team member and an initial assessment date will be identified through a partial booking system and the Service User, referrer and G.P. will be informed and sent information about the Service. (c) WAITING LIST The Service, will review the waiting list on a regular basis. People on the waiting list will be informed periodically of their status on the waiting list. From time to time it may be necessary to close the waiting list to new referrals. Service Users from outside the West Yorkshire and North and East Yorkshire area will be seen depending on Service commitments and constraints. First appointments will be offered through a partial booking system to maximise Service User choice. Inclusion criteria: Individuals with an initial diagnosis of transsexualism or gender identity disorder (see ICD categories). A local sector consultant psychiatrist must have given the initial diagnosis. Diagnosis may be reviewed during assessment in LGIDS. Service Users and referrers requiring consultation and advice about treatment and management of gender dysphoria. This may include those with dual diagnosis, e.g. depression, personality disorder and psychosis. Individuals requiring exploration and/or consultation without gender reassignment where specialist or experienced clinicians are not locally available. Individuals requesting gender reassignment for assessment with regards suitability. Individuals with post-operative concerns. This would be offered via a one off appointment. Individuals requiring hormone review. Again this may be offered via a one off appointment. Many cases have complex care needs, where joint care between the Leeds Gender Identity Service and local psychiatric and secondary care services may be necessary. In order to facilitate the best use of local services the LGIDS aims to develop its consultation arrangements with local services. Exclusion criteria Those under Seventeen years of age. Those with active acute psychotic disorder or acute mental illness. Those with untreated alcoholism and other addictions. Those with organic brain disease including dementia. Engagement with the Service Engagement of the Service User with the Service Clinicians is very important as it enables the Standards of Care to be adhered to by the clinicians and ensures the Service User receives a safe and quality service. It is also consistent with LGIDS philosophy and emphasis on a collaborative relationship between the Service User and Clinician. It aims to minimise inappropriate disengagement from the Service, facilitates confidentiality, appropriate trust and communication within the Service. Assessment will include the development of an agreed but flexible contract of care, over a specified period, in discussion with members of the Team, which includes: i) A secure and collaborative relationship between Service User and clinician. ii) An agreement about the frequency and duration of Outpatient appointments. iii) An understanding of the Did Not Attend (DNA) policy. The contract of care is applicable throughout all stages of treatment within this Service. Engagement process: Once a referral has been discussed the Service User will be allocated to a Team member (dependent upon current clinical workload and clinical needs assessed) who will make the first assessment appointment. When the Service User has been allocated to a Team member it is usual that they will continue to be seen by the same person during their contact with this Service (the Care co-ordinator). Following each Outpatient appointment the Team member will document in the Service User’s notes an evaluation of the session and the agreed care plan. Following Outpatient appointments relevant agencies involved in the Service User’s care will be informed of progress by letter as appropriate. If a significant risk to health and well-being is identified then each Team member is responsible for communicating this to the relevant agencies. During the initial assessment appointments, an agreed plan of care will be formulated between the Service User and Team members. Each Team member will follow this Service’s documentation standards and protocols guided by the Harry Benjamin International Gender Dysphoria Association’s Standards of Care. Transfer of service users from child Gender Identity Services to adult services If a service user has been diagnosed and treated for Gender Dysphoria in the child and adolescent services and has reached the age of 17 years, relevant referrals should be made to Leeds Gender Identity Service. This would need to include the usual referral from the clients GP to support shared care arrangements and one from the Consultant Psychiatrist treating the client. When the service identifies capacity to see the client and the appropriate funding is in place or there is capacity in relation to contracted number of clients seen in a specified area a first assessment appointment will be sent. Prioritisation will take place as considered clinically appropriate, this is in line with other specialist clinics. Transfer of service users from one NHS GIDS to Leeds GIDS when they move geographical area. When a service user attending an NHS specialist clinic for Gender Dysphoria moves within the Leeds Gender Identity Service area and wish to transfer their care to Leeds the same principle as above should occur. The service would need a referral from the client’s new GP supporting shared care arrangements on discharge; the service would also need an up to date report from the existing Psychiatrist / Psychotherapist who has been involved in their care, this would need to include details of the treatment they have already received within the Specialist Gender Service and any areas for concern. Once the service has capacity in relation to both caseload and contracted number of clients seen by the service an appointment will be sent. If an existing service user of LGIDS chooses to move area the new PCT will need to take responsibility for the finance relating to the clients care. The client may need to negotiate this with the PCT before moving area. This is to avoid disappointment. The GP would also need to contact the Local Sector Psychiatry Team to inform them of the client and the possibility of future involvement. (d) ASSESSMENT & CONSULTATION Initial appointment The initial assessment will be lead by the Consultant Psychiatrist and a clinical nurse specialist will also be present. The aim is to explore the Service User’s needs balanced against the appropriateness of this Service to meet these needs. A mutual decision between Team members and Service User is reached. This initial appointment will also include an explanation of what the Service can offer. This facilitates informed choice about whether or not to take up the offer of continuing the assessment process. If the outcome of this initial appointment concludes, either via a CPA review or after discussion, that the Service User is not appropriate for this Service or does not wish to take up this Service then the referrer will be informed in writing with reasons and with any recommendations from the Gender Team. If the Service User wishes to continue then they enter into the full assessment process. Following the first assessment appointment, clients will be offered an assessment period via a contract that will be negotiated between the Care co-ordinator and the Service User. The contract will be explained including the review process in which the Service User is an active participant, normally after three months equalling around 6 sessions. This may include meetings with two Team members together if appropriate. The Care co-ordinator and Service User undertake an assessment period of no less than three months. An assessment is developed and formulated with the Service User. The Life History Questionnaire will be completed and, where relevant, the views of significant others are used. To enable the clinician to evaluate the assessment with the Gender Team a CPA review, which includes the Service User, will take place at the end of the assessment. Throughout the assessment period an Assessment Form and Risk Assessment will be completed. Some outcome measures will also be used and will be completed by Clinician and Service User. Clarity of the assessment of each client’s needs and concerns is central to decision-making with regard to discharge or to planning the ongoing treatment pathway. A Care Plan will be completed with the client by the Care co-ordinator at the end of the assessment process and sent with an assessment letter completed by the Consultant Psychiatrist to the GP and referring Psychiatrist. “One Off” Consultation Upon receipt of a referral letter it may be felt appropriate to consult with the referrer, G.P., Consultant Psychiatrist or Key worker before seeing the Service User. Consultation may prevent a Service User entering this Service when it would not be appropriate. Consultations may be with a consultant psychiatrist, the prescribing doctor or another appropriate member of the team. Separate funding arrangements and waiting times are available. Pathway of care for clients with Gender Recognition Certificates When a service user enters the assessment phase of care and has already gained a GRC, a consent form should be in place ensuring the service has written consent documented to keep medical notes from biological gender accessible while the client is been treated within the service. When the client is discharged from the service the notes will be sealed by the Consultant Psychiatrist. The client’s care pathway would include assessment of eligibility and readiness for GRS. The care pathway for these service users would generally include six assessment sessions, referral for second opinion, referral for surgery, a minimum of three monthly appointments while waiting for surgery to take place and two final post operative appointments will also be provided. A GRC is a legal document and does not in itself denote readiness for transforming treatments. This is part of an ongoing clinical assessment. (e) TREATMENT OPTIONS (i) CONTINUING CARE & EXPLORATION OF GENDER ISSUSES Assessment can depend on emerging issues, thus assessment will be an ongoing process throughout he Service User’s contact with the Service Further exploration of gender issues, other psychological issues or social concerns may be deemed necessary without transition to gender reassignment. It may be identified that psychotherapy may be required before moving into the LGIDS pathway of care; this would be recommended to the GP who would need to make a referral to the local psychotherapy department. CPA reviews will take place with the aim of ensuring assessed needs are being appropriately met within this Service. (ii) GENDER REASSIGNMENT Treatment and continuing interventions regarding gender reassignment are initiated and monitored, namely the Real Life Experience, referrals for hormone reassignment treatment, speech & language therapy and surgery are also initiated by the LGIDS Team at the Newsam Centre. Again, continuing exploration and assessment ascertains the appropriateness of such interventions and as such is dependant on Service User involvement and the Clinicians/Team assessment and CPA review outcomes. Real Life Experience Clients will normally be expected to be living in the chosen gender role before referrals are made to speech therapy, hormone reassignment treatment and surgery. The Team should have had adequate opportunity to monitor and evaluate the nature of the Real Life Experience. This will constitute the assessment for eligibility and readiness for gender reassignment surgery. This Service aims to help Service User’s to reach a point in their gender expression and appearance that facilitates a comfortable enough lifestyle. This is a collaborative endeavour with regards to the pace of transition. It aims to help the individual work towards an integrated identity and sense of self that has personal meaning within the limitations that the transition from one gender role to another entails for different individuals and their circumstances. Therapeutic work seeks to explore the person’s fears or experience of prejudice, power inequalities, stigma and emotional problems as far as possible, including those of the therapeutic relationship in relation to gender issues. Support is provided towards living ‘in role’ or Real Life Experience, exploring the choices open to that individual and the consequences of those choices. Clients will be able to explore difficulties with living ‘in role’ and the potential for their resolution/management via the development of personal coping styles. Health education and information regarding living ‘in role’, surgery and hormones with acknowledgement to the limitations and expectations of treatment interventions is offered and alternatives thought about with the client. Communication between Professionals and Service User will be clear and uncomplicated and language used will be geared towards the facilitation of understanding. Communication should facilitate the expression of feelings regarding being on a gender reassignment programme and the need to satisfy certain criteria. The clinician will explore the consequences of the course of action the individual chooses to take. This may be challenging at times. Help will be provided with the preparation for living ‘in role’ including agreeing name change and date for commencing the Real Life Experience. The clinician will identify and explore potential losses of gender ideal, identity, family, friends, community and possible social consequences to gender status and work. The clinician will help facilitate independence, responsibility, assertiveness and problem solving. The Service User will be encouraged to use the therapeutic space to explore emotional issues and difficulties, especially while in the Real Life Experience. Exploration will be normalised by this Service allaying the fears of the Service User of being judged. Service Users should be encouraged to engage in the exploration of any difficulties so as to enable their resolution and/or management while in the Real Life Experience. Where there are concerns about the Service User’s ability to meet the criteria for gender reassignment treatment, this will be openly discussed and explored on an individual and Team basis, e.g. at reviews with the Team making clear their recommendations and with reasons given. Within the whole process the concerns of the Service User will be central with the Gender Team always attempting to act within the best interests of the Service User. Written evidence of “living in role” will be required from educational organisation, employer, friends or family. Evidence of Deed Poll change of name will also be requested. Hormone Reassignment Treatment THE ENDOCRINE CLINIC The clinic is held weekly at the Newsam Centre and is organised by a Consultant Endocrinologist. There is a Pharmacist available to support the Consultant and to advise the Service Users about hormone usage and its effects. The clinic will prescribe and monitor hormone reassignment treatment, including blood testing and providing health education. Referral will only take place after a full assessment period of no les than three month’s of RLE and will be based on the Harry Benjamin International Gender Dysphoria Association’s Standards for treatment of transsexuals. Decisions about referral will take place at the regular case reviews (CPA). The decision will be based upon current circumstances and clinical views about the Service User’s capacity to benefit. A letter stipulating how the patient meets eligibility criteria for hormone reassignment therapy will be sent to the Endocrine Clinic doctor by the LGIDS consultant psychiatrist. The Referral letters will be copied to the G.P. and sector psychiatry teams. A full physical examination, history of physical health and blood monitoring will take place at the first appointment. After the consultation appointment the clinician in the Endocrine Clinic seeing the Service User will send a letter to the LGIDS at the Newsam Centre with a copy to the G.P. and Sector Psychiatrist. This letter will contain details of the treatment plan and the clinician’s recommendations. The Service User will complete a Consent Form agreeing to treatment with the doctor in the clinic before beginning hormone replacement treatment. Communication with the Endocrine Clinic will be a regular two-way process with each arm of the Service keeping each other informed of any changes in medication, problems regarding attendance and any overall medical concerns. The Endocrine Service will negotiate shared care arrangements with the Service User’s G.P., which will include information about drug usage and probable side effects. Joint meetings between the two arms of this Service will take place on a regular basis for discussion of complex clinical issues and C.P.D. Following surgery and review, hormone treatment will be under the care of the GP with access to information and support from the clinic if necessary. Voice Work To provide a time limited, group programme to a specified group of clients within the service. To adhere to the LGIDS policies, procedures and Standards of Care and own professional guidelines for this client group. To liaise with appropriate Team members about individuals attending the group if a concern during the group becomes apparent. To work with clients within a group environment concentrating on voice work, relaxation of the body and confidence building. To work with LGIS to ensure feedback from the group is gathered at the end of each programme. Surgical Reassignment Treatment Referral for Gender Reassignment Surgery Referral for gender reassignment surgery will only take place after a full assessment period within the LGIDS at the Newsam Centre and will be based on HBIGDA Standards for Treatment of Transsexuals. This includes “eligibility”, the specific criteria that must be documented before moving on to the next step in the therapeutic sequence, and “readiness”, the specific criteria that rest upon the clinician’s judgement prior to taking the next step in gender transition Referral for gender reassignment surgery is covered by a SLA with the University Hospital of Leicester. Authorisation would need to be sought from the client’s home PCT only if the proposed surgery was not covered by the SLA (e.g. female to male gender reassignment or clients outside of West Yorkshire). For West Yorkshire clients who require female to male surgical intervention, funding will be sought in principle when the individual is accepted onto the pathway from their home PCT. Funding for surgery is usually arranged early with the local P.C.T. by the surgical Team The decision to refer for surgery will be made in the context of CPA and made by the consultant psychiatrist. It will be based upon a capacity to live successfully ‘in role’, tolerate hormone replacement therapy, benefit from the procedure and attend on a regular basis. Before referral is made a Second Opinion will be obtained. Usually a Second Opinion is sought from outside the LGIDS in the interests of good clinical care and impartiality. The person giving the Second Opinion will only be given full information about the Service User’s history and pathway through the Service to date in order to assist their decision on the clinician’s request or if there are specific risks. The Second Opinion will assist the Team in making a final decision regarding the Service User receiving gender reassignment surgery. A Second Opinion will be from a Specialist Psychiatrist or Psychotherapist working in a specialist NHS gender identity service and receiving regular appraisals. A Service Level Agreement across specialist services will be sought to enable Second Opinions to take place as quickly as possible, avoiding unnecessary delays. Funding for second opinions are included in the SLA which exist between LMHT and West Yorkshire, North Yorkshire and East Yorkshire PCT’S. For those clients outside of these agreements funding will need to be requested from their home PCT. The Service User must have been receiving hormones for eighteen months before receiving gender reassignment surgery. A referral may be made to a Surgeon in less time than this when taking into account the waiting list for surgical consultation. In some situations an early consultation may be arranged before a Service User is eligible for surgical treatment, i.e. to exclude surgery at a later date or to look at physical issues that have become upsetting to a Service User or to provide detailed information. The G.P., Sector Psychiatrist, local P.C.T. and commissioning bodies, as well as other arms of the LGIDS will be notified when referral to surgery is made. Following surgical consultation, the surgeon will write to LGIDS giving information about the consultation including clinical views about physical eligibility for surgery, any medical concerns and a decision about procedure. There will be a commitment from both arms of this Service to keep two- way contact during surgical procedure and in the immediate post- operative period as appropriate. LGIDS takes responsibility for being involved in physical and emotional preparation for surgery, including adjustment to hormone reassignment treatment, and for the psychological and social adjustments post surgical procedure, as appropriate. Post surgery physical adjustment will be the remit of the surgical team. At least annual meetings will occur with the surgical Team e.g. G3 meetings. (f) THE RESOLUTION AND DISCHARGE Discharge may occur at any stage of treatment, after assessment, after a Real Life Experience, after hormone reassignment or after surgery. The client and clinician work towards ending the therapeutic relationship, treatment and contact with this Service when it is perceived that the intervention of this Service is no longer required. It is recognised that many Service Users do not begin to deal with internal conflicts until treatment is completed, in which case a process of working through their difficulties may be required. Ending a contract with the Service depends upon negotiation between Service User and the Gender Team. When the decision to discharge the Service User has been made, the appropriate agencies are notified to ensure community support is available and the CPA will be implemented to facilitate this process. Where there has been gender reassignment surgery discharge will take place usually one year post-operatively. The discharge letter will be sent to the referrer, G.P. and any other agencies involved as appropriate. Failure to attend on two consecutive occasions without contacting the service may lead to a Service User being discharged. Other reasons for discharge may include drug and alcohol usage, severe mental health problems or social instability. If a first assessment appointment is sent out and the client fails to attend without informing the service, a second letter will be sent out asking the client to contact to reschedule the appointment within the next three weeks. If this offer is not taken up the individual will be discharged from the service. 3. CARE PROGRAMME APPROACH (CPA) The CPA is a framework to ensure that each Service User being seen by Mental Health Services receives the help and support they need and that this care is well organised. If a number of agencies are helping someone, as is the case within the LGIDS, the CPA aims to make sure that they all work together and know what help is being provided. Each agency should communicate its work with each of the other agencies. Any Service User who has multiple needs and input from other Services should normally have an established enhanced C.P.A. in place at the time of referral. The LGIDS will not be responsible co-ordinators for Service User’s who have severe enduring mental health problems that are subject to enhanced CPA with their local mental health services. All Service User’s who engage with this Service will be placed on standard CPA for this Service and a LGIDS care co-ordinator will be identified during the assessment period. The LGIDS care co-ordinator is responsible for maintaining contact with the Service User and other relevant agencies during their engagement with the LGIDS. The LGIDS co-ordinator is responsible for co-ordinating reviews during treatment and pre-discharge meeting prior to the Service User’s discharge from the LGIDS. A risk assessment will be carried out and the outcome communicated to the Team and any relevant agencies. Central to care and treatment is the Care Plan and relevant documentation that reflects the CPA process that clinicians will maintain as per professional guidelines. Due to geographical locations and clinical commitments of the other services delivering care, it will not always be possible for those professionals to attend the reviews at the Becklin Centre. In such cases the LGIDS will aim to communicate any relevant information regarding care and treatment via letters and copies of care plans and invite those professionals to contribute to the review in a way that is as practical as possible. In order that the principles of the CPA are adhered to as far as possible, the LGIDS will make efforts to meet with other agencies involved, via liaison meetings organised locally or within other services premises/departments. Service User involvement is of the utmost importance for successful implementation of the CPA, therefore, careful consideration will be taken in deciding how Service Users are involved in meetings. Other individuals important to the service user e.g. family members, close friends may also be invited to attend the CPA meeting. 4. ATTENDANCE STANDARD As part of the contract of care with the LGIDS, the Service User has a responsibility to keep in touch and communicate any changes or difficulties in attending appointments. They are, therefore, asked to cancel appointments in writing or by telephone, giving at least 48 hours notice, with a request for an alternative appointment. Equally, the LGIDS have a responsibility to inform Service Users with adequate notice of any changes that are made to agreed appointments, including cancellations. Service User’s who cancel appointments before the appointment date will be offered alternative dates. Should the Service User’s DNA without contact they will be sent another appointment by the clinician who oversees the Service User’s care and treatment. They will be informed in writing of the need to be monitored and that not being seen may be detrimental to their physical/psychological health and interrupts the co-ordination of their care. They will be politely reminded of the agreed contract, including the possibility of care and treatment being deferred. A copy of this letter will be sent to the Service User’s G.P. and agencies involved in their care. If a Service User fails to attend the second appointment a full CPA Review will be made (third appointment) where the Service User is invited to attend to discuss the difficulties or issues that are contributing to the DNA with the LGIDS. This review will occur in the absence of the Service User if they DNA. In these circumstances the LGIDS Team will discuss the case and make a conclusion based on the continuing assessment of this individual and make the necessary recommendations to this Service as a whole, including endocrine, surgical teams and speech therapy. A full letter will be sent to the G.P. and all Services involved, making recommendations. These recommendations may include discharge, other treatments and referrals being deferred or withdrawn. A copy of this letter will be sent to the relevant Service User. 5. IMPLEMENTATION OF STANDARDS OF CARE The Harry Benjamin International Gender Dysphoria Association (HBIGA) Standards of Care are an integral component of Service provision and are adhered to in order to maintain reliable and acceptable Standards of Care. These guidelines will be referred to within this Service until such time as they are superseded by any new national guidelines. HBIGA Standards Of Care include guidance on areas of professional involvement, the roles of the mental health professional, the training of the mental health professionals, eligibility and readiness criteria for hormones and surgery, documentation, second opinions, recommendations regarding the treatment of children and adolescents, psychotherapy, Real Life Experience, hormone reassignment and surgical reassignment including follow up. This Service aims to provide a continuing assessment via a care pathway. Members of the Team will use the following areas to evaluate the Service User’s situation: Social dimension Inter-personal dimension Psychological dimension Physical dimension Informational care is central enabling the Team to ascertain whether or not an individual understands what is and what is not possible from treatment and interventions and to revisit information periodically on different treatment options. Mental Health professionals are responsible for communicating their assessments, ongoing interventions and areas of concern on appropriateness for treatment to the LGIDS Team and other services involved via their role as a Care Co-ordinator as per CPA policy. Clinical Supervision of one hour per month is a requirement for the specialist nature of the therapeutic work as well as for continuing professional development. LGIDS belongs to the Gender Identity Network. 6. DISAGREEMENT & COMPLAINT Any disagreement between a Service User and the LGIDS Team will be managed in an open and professional manner. If a situation should arise where a Service User in treatment is in disagreement with the Gender Team, the following will take place: (a) Every effort will be made to resolve the disagreement informally within the clinical arena in the first instance, either through a full meeting of the Gender Team with the Service User or by a one-to- one meeting with a preferred Team member. (b) A referral to an outside specialist in gender identity disorder can be made for a second opinion. (c) The Clinical Services Manager or Clinical Team Manager can intervene on the Service User’s behalf and be in contact with the Service User on an informal basis. (d) The Service User may use the Trust’s formal complaints procedure and will be given assistance to do so in the case of verbal or written complaint. ADDRESSING COMPLAINTS When a formal complaint is made by a service user against a medical practitioner the complaint will be sent to the Associate Director of the specialist services directorate with a copy sent to the Clinical Service Manager and Clinical Team Manager. The complaint will be investigated by the Associate Medical Director. If a complaint is made against another clinical member of the team the complaint will be sent to the Associate Director with a copy sent to the Clinical Lead and the Clinical Team Manager. These will usually be investigated by the Clinical Service Manager. With regards to general service complaints these will be sent to the Associate Director, with a copy to the Clinical Service Manager, Clinical Lead and the Clinical Team Manager. These will generally be investigated be the Clinical Service Manager. 7. CLINICAL GOVERNANCE AND EVALUATION The Service is part of the Specialist Service Directorate and takes part in the directorate’s arrangements for clinical governance. Staffs attend the Clinical Governance Council of the LGIDS, which include review of Service User involvement strategies, risk assessment procedures, organisation of information and communication, clinical audit, research and training developments, access to services and public health issues. The Gender Identity Service is constantly alert to developing its clinical governance strategies relevant to the service requirements and these are discussed monthly. The Lead Clinician for the LGIDS is responsible for ensuring that clinical governance procedures for the Service are sound and appropriate and chairs the Clinical Governance Council. The Lead Clinician and Clinical Team Manager are both members of the specialist services Clinical Governance Council which meet monthly. User involvement: The views of the Service User will be encouraged, sought, carefully listened to, documented and taken into consideration by the Gender Team. This principle will be adhered to throughout the Service User’s contact with this Service. Clinicians and Service Users will have regular forums with management to evaluate clinical practice and other relevant issues affecting this Service as a whole. Self-help groups will be supported where possible, including education and outside contributions, e.g. from ex-Service Users. Patient Satisfaction Assessment forms will be given to Service User’s who complete service intervention to evaluate their clinical outcome, their experiences and satisfaction levels. Service Users also have access to the Trust Service User Liaison and Advocacy Services (PALS). Service User’s will be put in touch with PALS The team has an identified lead in service user issues. The Gender Identity Service is part of the Northern Network for Gender Identity Services, which meets twice yearly and comprises representation from Leicester, Nottingham, Sheffield and Leeds services at the current time. There is regular external supervision / case discussion on a monthly basis from a Specialist Psychotherapist and occasional visiting speakers. Clinical governance issues are reviewed regularly with the Associate Medical Director for Specialist Services directorate, the Associate Director and the Clinical Services Manager. 8. SERVICE HOURS The LGIDS operates Monday- Friday 9 a.m. to 5 p.m. The Endocrine Clinic currently operates on a Monday evening 6.00pm- 9.00pm. Where possible appointments to different parts of the service will be co- ordinated to reduce transit. This Service closes during Bank Holiday periods. Telephone messages can be left on the answer phone out of hours and the secretary at the earliest possible opportunity will return calls. Tel: 0113-305-6346. Service User’s are offered specified appointments of 50 minutes duration at intervals negotiated between clinician and the Service User. These appointments can be agreed in session with the Service User or in writing via an appointment letter. As a tertiary Service we do not offer an emergency service. Therefore, in such cases Service User’s will seek assistance from their G.P. or other rapid response Services. 9. THE TEAM The LGIDS Team will take a collective responsibility approach to care and treatment, clinical situations and in its relationship to the management of this Service. The Mental Health Team at LGIDS comprises of three clinical nurse specialists, one clinical team manager, one part-time Consultant Psychiatrists, a sessional Consultant Endocrinologist, a full time Occupational Therapist and a full time Team Administrator. Together they provide the core Service including CPA case reviews. The Consultant Psychiatrists makes all referrals on to the other arms of this Service The Endocrine Team includes a prescribing doctor and a pharmacist. There is a voice coach working on a sessional basis within the service. The surgical Team at Leicester will accept between ten and twenty referrals per year. A maximum of ten of these referrals are funded by west Yorkshire. All Team members will be conversant with their own Trust’s clinical policies and procedures relevant to their clinical setting and professional guidelines. The core Gender Identity Team will hold team meetings regularly. Cross Service meetings including the surgical teams will be held quarterly (the Gender Network) Mental Health professionals in training do placements within the Service. THE CLINICAL NURSE SPECIALISTS To utilise the implementation of the standards of care as set out in the Clinical Protocol to guide assessment, intervention and planning of care. To establish and maintain a therapeutic relationship to inform, support, empower, monitor and educate the Service User, provide advocacy and continuity of care To communicate areas of concern and progress on appropriateness for treatment to the gender Team/relevant agencies. To ensure standards of care are being met and partake in audit activities. To participate in Service development. To comply with Service/Trust policies and protocols. To ensure clear concise documentation written notes, assessments and care plans are maintained in line with professional guidance. To effectively manage clinical case load/workload. To provide education/training to other relevant agencies. To provide/engage in regular clinical supervision and C.P.D. as appropriate. To report concerns as appropriate to the Consultant Psychiatrist, Clinical Services Manager or the Clinical Team Manager. To set up CPA review meetings and take on role of care co-ordinator. THE CLINICAL TEAM MANAGER To ensure that this Service is effectively co-ordinated and runs smoothly across Trust boundaries. To ensure Service User’s needs are met within a safe environment. To ensure team members comply with the philosophy of this Service and deliver care through the interventions discussed within individual Service User care plans. To ensure staff comply with Trust policies/protocols and are safe at work. To participate in Service development. To cascade relevant information to other members of the Team and ensure that all staff are made aware. To act as a resource on clinical/management issues. Delegate tasks to the most appropriate Team members. To review and update Service policies and protocols. To work with Service User’s to develop this Service. To hold a small clinical caseload and participate in Team CPD To liaise with other relevant agencies involved within this Service. Monitor staff sickness/performance. To maintain effective communication systems with all agencies including commissioners. Develop and maintain adequate systems for statistical information. To hold monthly Team meetings. Appropriately keep the Clinical Services Manager informed of issues affecting this Service and ask advice on managerial issues. Implement clinical governance decisions. To be involved in clinical audit. THE CONSULTANT PSYCHIATRISTS (and LEAD CLINICIAN) To participate in the overall focus and directions for this Service in collaboration with management. To offer expert advice to staff members, primary, secondary and tertiary Services and other agencies on a variety of treatment strategies for Service User’s with Gender Dysphoria To participate in review, C.P.A., Team meetings, assessment, referral to Endocrine and referral for surgery. To be responsible for referring by letter Service User’s to the endocrinology and surgical arms of this Service. To provide second opinions to other services. To diagnose and, in collaboration with Service User’s and members of the LGIDS Team, discuss and plan treatment. To support an ethos of team working. To provide discharge and assessments letters in conjunction with the care coordinator. To contribute to first assessment appointments. To undertake personal supervision including continuing professional development. To take the service lead in audit and research and other aspects of clinical governance THE PHARMACIST Work with the Hormone Reassignment Doctor in the Endocrine Clinic. Provide Service Users with accurate and up-to-date information about hormone reassignment treatment for gender reassignment. Support health promotion and educational initiatives for Service Users. Support GP’s in their understanding of these drugs in relation to transsexuals. Contribute to the development of shared care guidelines and other endocrine policies. Ensure relevant drugs are safely available and appropriately prescribed at the Clinic. Contribute to Team meetings. Maintain appropriate C.P.D. Contribute to clinical audit activities. CONSULTANT ENDOCRINOLOGIST Lead the hormone reassignment aspect of the Care Pathway working with the Pharmacist. Assess all new Service Users starting hormone reassignment therapy. Gain consent of Service Users for hormone reassignment therapy. Ensure Service Users expectations are adequately addressed before treatment is initiated and that limitation and risks of therapy are understood. Ensure that all Service Users have relevant tests and investigations during hormone reassignment therapy. Provide health monitoring including physical assessment. Maintain case notes under C.P.A. framework Liaise with G.P.’S with regard to shared-care arrangements. Liaise with the surgical team regarding safe hormone usage prior to, during and after surgery. Prescribe hormone treatment for gender transition with the support of the Pharmacist. Support health promotion initiatives with other Team members. Contribute to team meetings on a regular basis and alert the C.S.M., Clinical Lead and C.T.M. of any problems related to medication. Maintain appropriate C.P.D. Contribute to audit activities and service development. THE CLINICAL SERVICES MANAGER To provide overall management input into the Service. To provide strategic direction to the Service in collaboration with Team members. To contribute to any major decisions that are made by the team. To delegate appropriate management tasks to the Clinical Team Manager and to supervise his/her organisational responsibilities. To contribute to Service development. To work in collaboration with the Clinical Lead and Team to ensure a high quality service. To contribute to the establishment and maintenance of good communication links with the Clinical Team Manager and Clinical Lead. To ensure that the Service is delivered within the parameters of the Service Level Agreement To ensure that the Associate Directors (City Wide) are appropriately briefed on the Service performance. To attend monthly Team meetings and other meetings as required and thus provide appropriate management input into the Service. To act as line manager for the specialist nurses working in the Service. To liaise with the Lead Clinician and Associate Medical Directorate as required. To take on any other management responsibilities as required. THE TEAM ADMINISTRATOR To respond to telephone calls including the answering machine and maintain patient confidentiality. To collect data for the Trust and service requirements. To provide relevant secretarial and administrative duties to support the clinical work, e.g. letters, appointments, minutes of meetings, etc. To arrange supplies. Maintain good communications with Service Users. Create safe filing arrangements. THE OCCUPATIONAL THERAPIST To Act in the role of care co-ordinator to a specified group of clients. To take a specified number of referrals for Occupational Therapy specific interventions. To introduce and use evidence based OT specific assessment tool within the service. (MOHO) To lead on the development of group work within the service in the areas of activities of daily living. To contribute to service development. To take part in regular Clinical Supervision To ensure trust and service policies and procedures are followed. To establish and maintain a therapeutic relationship with clients. To be guided in practice by the standards of care used within the service.
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