Leeds PFT Schedule 1 Service Specification by 203QFTkG

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									                                                                              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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