Thread by @MPTS_Hearing

Hello, welcome back to Day 2 of Dr Webberley's hearing. Proceedings are due to start at 10.30am.
Dr Webberley's (Dr W) counsel is Mr Ian Stern, QC (IS) and the GMC counsel is Mr Simon Jackson, QC (SJ).

The Tribunal Panel consists of a legally qualified Chair, a medical professional, and a lay member. We are expecting the panel to make an announcement on the contested evidence submitted by the defense yesterday, as to if it is admissable or not.

We've been informed that the proceedings will not begin until 11.30. We've not been told why. See you back here at 11.30.

The hearing has started and the Chair is announcing which evidence is not admissible. The panel states that an email will be sent with the draft determination, with reasons included.

Counsel for GMC, SJ says they would like to make a brief application, but first wish to verify a particular document. Chair suggests a break to read through the reasonings. Agreed to resume at 12.10.

Counsel for the GMC, SJ acknowledges that the application should have been made at an earlier date. Says he accepts responsibility and that they are trying to tidy up the allegations.

SJ requests beginning with Patient A. He says that following the initial consultation, Dr W failed to provide good clinical care and did not obtain an adequate medical history.

SJ says that the proposal is to insert the word "adequately" as the standard that is set is "to provide adequate care". SJ says that the word adequate just means what is expected of every doctor.

SJ is reading through the allegations and discussing the 2015 Good Medical Practice guidelines on adequate assessment/diagnosis.

SJ says that the assertion is that Dr W did not explore diagnosis of ADHD. He says there was a failure to provide a full psychological assessment and did not explore co-morbidities.

Regarding Patient C, SJ says that Dr W "Did not arrange for Patient C to be examined". SJ says there is no expert evidence that suggests that anyone has been advised to express an opinion on adequacy/inadequacy.

Dr W's counsel, IS refutes that patient C was not examined. "In the chronology, HW writes a letter describing face-to-face consultation...if you look at bundle 412-413, the date is clearly 11th August"

IS objects to the proposed changes and he questions why the charge that Dr W prescribed testosterone has not been removed, given that the patient was never prescribed testosterone.

IS says he objects to the amendments. He says there have been a number of versions of Heads of Charge that they've had to look at, that were added to following the expert review at end of March.

IS says that the notice of hearing was served on 21 June 2021 - "the lateness of any amendment is inherently unfair." He says that the amendment seeks to widen the scope rather than narrow it.Adds that no new evidence that has surfaced surrounding patient A.

IS asks the panel to look at what Dr Agnew says on p. 222. Dr Agnew: "There was a thorough, well-informed and appropriate exploration of gender dysphoria...the psychology input did not fully explore other diagnoses e.g. ADHD"

IS states there is an issue with the report of patient C and the allegation should be at Dr Pasterski.

IS states that in short, what this appears to do with adding new wording is to completely distort and extend the allegations.

IS says that regarding the physical and psychological assessment (1b2), according to GMC witness Dr Agnew, this was thorough and well-informed.

GMC counsel, SJ says that he disagrees. He says all cases brought by GMC are built on what is considered good medical practice. he says amending the change does no more than make sure that point is underlined.

SJ does not accept that this change widens the scope. He anticipates that Dr Webberley understands that good medical practice applies to all and submits that that is exactly how a Dr should approach any assessment.

SJ says the role of the prescribing doctor requires an approach that involves taking a full medical history, and requires the patient to be examined physically and psychologically

SJ claims that in relation to patient C, there wasn't an adequate report and that the duty of a prescriber is that this assessment has been carried out to an adequate standard and ensure that the report is thorough.

SJ underlines that this does not provide for (in relation to Patient C) adequate assessment. he says that there was no parallel psych assessment - only an independent assessment in relation to Patient C.

IS states allowing this last minute change would set bad precedent - that the GMC can always add last minute changes just because it's "good medical practice". He says that "Good medical practice" is not a solid basis for an application to amend.

In response to a question from the Chair about the allegation Dr W prescribed testosterone to patient C, GMC counsel SJ says he will need to go back and check with patient C -

- but SJ says whether testosterone was prescribed or not is irrelevant as the same checks should have been carried out.

A discussion is happening about the relevant rules governing the tribunal, whether to accept amendments or not.

Chair says one of the matters considered is whether the defendant could have discerned the nature of an allegation which could be amended, or whether it comes to them entirely fresh.

Chair has they hope to have response by 2.30pm and asks can SJ make his application this afternoon? SJ says they will as soon as they can. SJ says that Patient C was prescribed T in due course.
Adjourned until 2.30pm.

The tribunal have decided that in 1b, 3b and 5a they will allow the word "adequately" to be added. The said they will draft the reasoning later. Dr W will now plead to the allegations. (IS will reply on Dr W's behalf)

Dr W admits to 10a, 28a, 28b and 29. These relate to issues to do with Dr W's prior conviction and regarding membership of the RCGP. Dr W denies all the other allegations.

SJ is saying that usually by the time the GMC gets to this point, they usually have clarity over bundles. But as recently as lunchtime, they don't know if medical records of Patients A, B and C have been uploaded & agreed.

Discussion is happening as to where medical records and witnesses sit in the defense bundle. The Chair says that the bundles need to be formalised.

IS says they are still waiting to be given the signed statement from Patient A's mother, but that they will have all they need.

SJ says the GMC are waiting to hear from the defense as to if the latest bundle can be uploaded. Some of the bundles have problematic numbers. Lots of discussion about bundles...

SJ says that Dr W has previously described herself as Senior Director of Gender GP and specialist practitioner in gender care. Dr W practised as an NHS GP since 2016. Qualified from Uni of Birmingham, Social Medicine 1992.

Dr W has been a member of WPATH since 2015 and has produced educational resources for Mermaids. MRCGP in 1996. SJ questions whether she can use MRCGP. There is no doubt she passed the exams, but GMC argues that she cannot be a member.

Dr W completed a course in psychosexual practice in 2002, gender variance course in 2015. Left her job as a GP in 2016 to help trans people and "set herself up" as an online practitioner with a specialist interest in gender dysphoria.

SJ says he will address the following issues: what is gender dysphoria, how has treatment evolved, how is the issue of treatment approached, how guidance and protocols been been created to cover this area.

SJ notes there is no formal training for Drs wishing to specialise in this area. SJ says he will discuss issues surrounding consent and capacity to consent and will look at Patient A, B & C in turn to see what experts say.

SJ says that GD is defined in DSM5 with a separate diagnosis for children. SJ says that GD must last at least 6 months and lists the criteria for a GD diagnosis. "It lasts at least 6 months" is important to the GMC case.

SJ says that although GD is considered a medical diagnosis it is important to stress that GD is a psychological condition that sometimes requires medical treatment. He says that when considering transition there are 3 separate stages,

Stage 1: puberty blockers, stage 2: the administration of cross-sex hormones, and stage 3: gender reassignment surgery, which is only available via adult
services to people aged over 18.

SJ asks the tribunal members to consider the guidance that was available in 2016 when they are considering the charges as since 2016 there has been further guidance.

SJ says that some of this will give us insight into how treatment has developed. But Dr W must be judged by 2016 standards. SJ says it's important to distinguish between treatment of children, adolescent, and adult patients.

SJ says that the timing of treatment with children needs to be carefully timed as they haven't gone through puberty yet. Certain criteria must be met for a child under 16 to be able to consent to treatment.

The patient must be able to acknowledge what changes they can expect and how they think treatment will help. They also need to understand the effect on their physical, mental, and emotional wellbeing and the uncertainties of how it may affect them in the future.

SJ states that the GMC observe that when children as young as 12 are allowed to consent to PBs that they may choose to go on at 16 to Cross Sex Hormones (CSH), which are not fully reversible.

SJ states that decisions about patients are balanced on the fulcrum of their current crisis and that key questions before prescribing are: has it been over 6 months and do they have the correct support?

SJ cites various international guidelines for best practice including a 2016 Amsterdam Clinic paper, a protocol on psychological pediatric endocrinology.

From a 2006 paper "treatment outcome is expected to be more favourable when it begins after Tanner Stage 4/5, when they have had lifelong dysphoria, are psychologically stable and live in supported environment".

SJ says that "suppressing puberty should be seen as supporting treatment, but not *as* treatment" and that this was considered best practice at the time.

SJ says "Parent and child consent must be obtained." He adds that the child must be seen by a psychiatrist to dampen any unrealistically high expectations of future life and ensure they are informed of limitations for e.g on sex life.

Regarding the criteria for GD SJ says the patient is always seen by two members of the team. The decision regarding medication is always made by the whole team as per guidance from 2006. SJ says this guidance should be used to compare Dr W's approach.

The 2006 document is important for 3 reasons says SJ, because it details:
- whether they should be treated
- how
- time taken to complete these stages

The paper says that "adolescents eligible for hormones are 16 years or over" says SJ.

SJ says 2008 NHS guidance on the care of gender variant people stated the role of the GP: "GPs may prescribe hormones or refer to specialists. GP may develop special interest & treat or make local referrals to multi-disciplinary teams".

SJ adds that he anticipates Dr W seeing that as endorsing her role.

SJ, reading from guidance says "It is desirable that patients are treated locally if possible." and that, "GPs with special interest can make the necessary referrals to multi-disciplinary care" (endocrinology, speech therapy etc).

The guidance also says that treatment for the gender condition should not be delayed unless strictly necessary for clinical reasons.

SJ says the question is not whether Dr W thinks she's a specialist, it's whether others consider her so.

SJ says that one of the issues - and we anticipate, the defense - regards bridging prescriptions. (e.g. for distressed, suicidal patients). SJ says that Dr W wrote bridging prescriptions for patients who were self medicating.

SJ says that patients who are already self medicating should be brought in to be helped and that a bridging prescription can help these people. He adds that hurrying them down the pathway can also have serious consequences.

Prescription can be used to bridge this distress while effective intervention takes place. SJ says young people presenting as the opposite gender are statistically more likely to be gay adults.

SJ reads from the guidance: "Where the patient is a child, family & school support is essential...Many will desist & grow up gay/lesbian. But some will continue with serious distress."

SJ says that PB may be prescribed once puberty starts with the support of a pediatric endocrinologist. SJ discusses the importance of a multi-disciplinary approach to treatment - including pediatric endocrinologist & psychiatrist.

NHS guidance at the time stated that: "A diagnosis of transexualism in a prepubertal patient cannot be made with confidence."

SJ says that experts must be able to diagnose co-morbid mental health problems and facilitate multiple appropriate interventions. Properly informed consent must be gained before HRT, potential side effects must be considered.

SJ says that the timing of medical treatment is important and it should follow rigid protocols including a pediatric endocrinologist and a counsellor. SJ stresses there needing to be a MDT.

WPATH 2012 guidance on the competency of MH professionals working with adolescents & children says minimum credentials: trained in developmental psychopathology, competent in treating mental health.

SJ says WPATH also stresses multi-disciplinary approach and says if this is not available, they must still engage a pediatric endocrinologist. Patient A was already engaged with the GIC, says SJ. GMC's contend that HW did not engage with the GIC.

SJ discusses the competencies & credentials required by various guidelines that were current in 2016 e.g. Master's degree, research in the field. he refers to NHS guidance:

"GPs are encouraged to collaborate with gender identity clinics (GICs) on diagnosis and to develop treatment pathways"

SJ says that the treatment of trans people is primarily provided by GIDS. He says the GMC recognises that GOPs play an important role in supporting trans patients in providing non-specialised help and that GPs are encouraged to collaborate with GICS.

SJ asserts that Dr W set herself up as a consultant and that her practice was to prescribe without an endocrinologist and then pass the shared care to the patient's GP.

"When prescribing an unlicensed & experimental medicine, you must be confident in its efficacy & safety." says SJ. He says GPs must take responsibility for prescribing, ongoing care, monitoring, shared care agreements and maintain clear record keeping.

SJ says when not following common practice you would need to keep clear records as to why you are prescribing.

SJ says you must allow patients to make an informed decision by providing them with the full information and making it clear you are not prescribing this for its intended use.

SJ says you must also gain written consent. The Chair suggests a short adjournment, due back shortly

SJ says that the GMC do not identify the medical qualifications of practitioners. Nor do we set the age at which patients can embark on treatment. He says the GMC's role is to provide regulatory framework.

SJ says It's important to understand whether Dr W was competent and experienced enough to prescribe to these patients. He says when practitioners take on responsibility for this care they must practice within the limits of their competence.

SJ asserts that Dr W didn't have the experience to prescribe to these patients. He says the tribunal is not about the principle of providing blockers or hormones. This is a recognised and widely-adopted treatment.

Central issue is whether Dr W, a general practitioner, was competent and experienced enough to meet the needs of these patients. Did Dr W obtain detailed psychiatric support for assessments?

The GMC contends that she should have liaised with GIDS and Tavi first and obtained records, before starting patients' regimen.

SJ says the GMC does not take issue with HW's publicised role in advocating better treatment for trans patients. Nor is this case about HW's status as a GP.
The GMC recognises that some GPs have acquired additional special interest areas.

SJ says Dr W was not formally labelled as a GP with a special interest in sexual health or with trans patients. As recognised by WPATH "There must be a difference between a specialist and a 'self-described' specialist".

SJ says that Doctors outside of a hospital setting cannot specialise in transgender medicine. He says Doctors must not assume roles or elements of roles that they are not qualified to undertake.

SJ says "people achieve accreditation & experience in hospital settings. Not to say that GPs can't develop these competencies, but they must regularly take part in activities that extend these competencies" and that Dr W should have taken advice from the GICs.

SJ says that to specialise in transgender healthcare you must partake in work experience in a GIC or a registered private transgender clinic. The GMC alleges that Dr W did not undertake the necessary work to acquire competence.

Dr W's experience of giving drugs to many trans patients is not sufficient to be a specialist states SJ, he says that there is no evidence of Dr W engaging in regular supervision or a MDT.

The GMC observe that Dr W's CV didn't show the required experience to work in this way with transgender patients. SJ says that not all children with gender variance will elect to transition and that there must be proper reflection on the unknowns with these treatments.

SJ stresses the importance of supervision and working with MDT - child & adolescent psychiatrist, psychologist, endocrinologist

SJ says that while Dr W is an experienced GP who has taken an interest in GD youth, who has written and taken part in international conferences, he adds that forceful advocacy should not interfere with the prescription of blockers and hormones to young people.

SJ raises concerns that there has been a correlation between PB to CSH, he says that there remain many unknowns about treatments with such profound physical and mental implications. Can young people understand the difficulties?

That is the end of today's hearing, SJ will complete his evidence at 9.30am tomorrow. IS is requesting that each tribunal member have their own camera as IS and, SJ and Dr W cannot see their faces. the Chair said they will look into it.