Thread by @MPTS_Hearing

Day 3 is due to start at 9.30, follow us to stay abreast of Dr Webberley's hearing.

Today we're expecting to hear from Prof Gary Butler, consultant in Paediatric & Adolescent Endocrinology at University College London Hospitals. PB has “a specialist interest in Endocrinology and is the Medical Endocrine Lead for the National Gender Identity Development Service”

Chair invites SJ to continue with the GMC's opening. SJ and IS have discussed disclosure issues. There will be more material from each party later on. Updated allegation sheet has been handed out with the word ‘adequately’ added.

SJ is returning to his opening. The GMC observe that Dr W sought to make herself a MDT. He says these children were frustrated by the wait lists and approached Dr W to access treatment, and this lead to them potentially being dropped by the NHS.

SJ says that Dr W wrote that she offered, "a similar service to the NHS GIC, but in a more timely fashion and I have accumulated a large amount of experience in treating transgender people"

SJ says the standards were not on par with the NHS. The members of her MDT did not have the same qualifications as those that work at the GIC. If HW was trying to fill a perceived gap in the NHS, care shouldn’t be given at a lower standard.

Providing vulnerable patients with prescriptions online is fraught with difficulties and no shortcuts must be taken, states SJ. When prescribing gender-affirming hormones, the doctor must first consider coexisting mental health concerns.

SJ says there are dangers with not distinguishing other issues from gender dysphoria and there should be many checks before prescribing hormones to a child, including a full psychological evaluation and checks from a pediatric endocrinologist.

SJ says we must refer back to the established 6 months of gender dysphoria too as many patients experiencing gender dysphoria also experience other mental health problems. Care should only be provided to children in consultation with a pediatric endocrinologist.

GMC submit once a patient has been fully assessed with their full background medical history, only then can a diagnosis be considered.

The monitoring after of those patients prescribed treatment is just as important to ensure they are being prescribed the correct dose of CSH and that their mental health is okay.

There are obvious dangers in prescribing online to this cohort of patients, says SJ. It typically involves dealing with patients or relatives requesting or petitioning for prescription of gender-affirming hormone treatment.

With respect to patients that this tribunal will discuss we must consider whether they had the capacity to consent to the treatment, states SJ. In the case of Bell v Tavi they primarily considered the age of consent and SJ says some parallels can be drawn to this case.

The Gillick competence test states that a minor under 16 should be able to consent, provided that they understand the risks of the treatment and the implications they may have, says SJ.

SJ says that parental consent may override the child’s consent. The issue is whether Dr W adequately assessed the patient’s capacity to consent.

SJ says when applying the facts of this case we can decide if the child has "Gillick competence" to consent to the treatment being proposed by Dr W.

He adds that a patient suffering from gender dysphoria may be under so much distress that they cannot fully understand the risks and implications.

SJ discusses an example of Anorexia Nervosa, as an example that they are not ‘Gillick Competent. The GMC submits that the prescriber should also consider whether a patient has the capacity to consent, given their mental health.

SJ posits that a gender dysphoric patient who presents with suicidal ideation may not be able to give consent to treatment, he says it would require continued monitoring. GMC submits this didn’t happen with Dr W.

SJ references the Bell v Tavi case, the ability to consent is deemed as an individual one depending on the patient. Not all children can meet Gillick Competency, it will depend on their maturity.

The child does not need to understand every aspect of the treatment and causes but they must be able to understand the key aspects. In the case of PB and CSH fertility must be understood and explained fully by the doctor.

SJ says in 2016 there was clear guidance on what approach to adopt regarding adults experiencing gender dysphoria. He says it is "common sense" to apply this guidance to children.

The GMC recognise that there is a concern for patients self-medicating. This challenge may be met by a doctor prescribing bridging prescriptions.

When a doctor is faced with this decision there is guidance on how to approach this. When a patient is self-medicating a clinician can provide a temporary bridging prescription until more permanent care can be found.

SJ says that Patient A (Pt A) was known to be seeing the Tavistock & Dr W decided not to contact the Tavistock to discuss the patient's care. Providers that prescribe bridging hormones must work with a GIC to ensure the patients' care is taken over asap.

SJ says that some patients find it difficult to disclose their feelings of GD to their local GP. This can lead to a delay in accessing treatment and self-medicating. PB and CSH can be found easily on the internet.

Bridging prescriptions must only be supplied for a short period of time after the doctor is satisfied that the patient can consent fully to the treatment and that they understand the risks, says SJ

SJ states the Dr W should have considered what point the child was at in being engaged with a GIC, as a GIC would be preferable. SJ says that dosages should be in line with the current guidance to obtain the optimum results in the safest way.

SJ states that providing sachets of testosterone as Dr W did, means that it cannot be delivered in the correct dose.

SJ states that if the patient requests treatment for GD that best practice is to refer them straight to their local GIC. Patients may face a long wait before seeing a gender specialist states SJ.

Transgender people face much higher rates of suicide and self-harm and GPs should refer them to a local mental health centre if they feel they're at risk.

SJ discusses when bridging prescriptions are appropriate, reiterating how important it is to support patients that are already self-medicating as they are at the most risk.

SJ states that a GP should only prescribe a bridging prescription if all the following criteria are met: a) the patient is already self-medicating b) the medication is to reduce the risk of self harm/suicide c) the doctor has sought advice from the GIC.

Council has requested a short break to read through the evidence that is due to be discussed shortly. Adjourned until 10.55

SJ states that he finds it problematic that the GMC does suggest that bridging prescriptions should be issued by GPs, as it is beyond their competence.

In the case of gender dysphoria, SJ says that most GPs will have no experience with dealing with these patients. He says that the treatment for transgender patients is extremely specialised and should be provided by specialists, not GPs.

SJ summarises that his key concern is that the GP can prescribe safely. he claims that the GMC's suggestion that GPs should prescribe bridging prescription forces GPs to act out of their competence.

SJ says patients need access to specialist treatments, which is the responsibility of the NHS, so GPs should only consider bridging treatments in “exceptional circumstances.” This should be part of shared care with a GIC.

The GMC go on to say it is perfectly acceptable to prescribe unlicensed medicine and quite common. They recognise the difficult position that GPs are in considering the long wait lists that patients with GD

SJ says that the GMC don't want GPs to feel forced into prescribing outside of their competency.

SJ says that the GMC refute the idea that prescribing CSH is an extremely specialised treatment as the same medication & guidance is used with patients with prostate cancer & endometriosis.

SJ says patients need access to specialist treatments, which is the responsibility of the NHS, so GPs should only consider bridging treatments in “exceptional circumstances.” This should be part of shared care with a GIC.

The GMC go on to say it is perfectly acceptable to prescribe unlicensed medicine and quite common. They recognise the difficult position that GPs are in considering the long wait lists that patients with GD

There were concerns about Dr W's treatment of Patient A, states SJ. Pt A was 12 at the time and had been under the care of the Tavistock for the last 2 years. Patient's A family contacted Dr W through her website MyWebDoctorUK.

There is no evidence of Dr W engaging in an MDT. A gender specialist must always work within a MDT says SJ, adding that there is no evidence of Dr W engaging in regular supervision.

To ensure Pt A had received the correct dosage of testosterone, a different method of application, other than a "quarter of a sachet" should have been used, states SJ.

SJ explains there is no evidence of a MDT approach to Pt A from Dr W and no physical examinations. SJ says testosterone being prescribed in sachets is unsuitable.

SJ states that as no MDT meeting had taken place, according to guidelines Pt A should not have started treatment. There was a failure to monitor the psychological well-being of the patient after prescribing testosterone in Pt A.

SJ states that as no MDT meeting had taken place, according to guidelines Pt A should not have started treatment. There was a failure to monitor the psychological well-being of the patient after prescribing testosterone in Pt A.

SJ discusses Patient B. Dr Walters was concerned that Pt B had been prescribed testosterone by Dr W after being referred to the local GIC. Pt B stated that he was taking half the "normal" dose. Dr Walters was concerned about Pt B's mental health but did not discuss this with him.

Dr Walters asked Dr Webberley to clarify the treatment plan of Pt B's medication. Dr Walters was not satisfied with the care that was described by Dr W and questioned which checks had been carried out, says SJ.

Pt B and his mother stated they were happy with the care they were receiving from Dr W and that they were hesitant to reengage with the GIC. After persuasion, they agreed to reengage with the adult service and Dr Walters subsequently prescribed a bridging prescription.

SJ states that Dr W's care fell seriously below the standard of adequate medical care by her failure to engage with the GIC or Dr Walters, failure to adequately monitor the patient after, and failing to keep proper notes.

Pt B, at 17 was prescribed testosterone by Dr W. Issues of consent are also raised regarding Pt B states SJ. SJ reiterates the need for an MDT and adequate care and monitoring.

SJ refers to statements from Dr Dean and Dr Agnew alleging that Dr W failed to explore an alternative diagnosis for Pt B.

Patient C, assigned female at birth, aged 11 was prescribed puberty blockers by Dr W. Dr Dean maintains that a copy of a signed informed consent sheet should have been obtained from the patient and their mother which wasn't done by Dr W.

In 2017 Dr Patel contacted the GMC about concerns regarding patient C, says SJ. Pt C received the closest treatment to what you could consider a MDT approach as he was seen by psychologist and gender identity specialist, Dr Pasterski

SJ says that Dr W diagnosed Pt E with an STI without the appropriate checks and that she claimed to be a member of the Royal College when she was not. He adds that she was encouraged to join but didn't reply.

SJ states that the Royal College wrote to Dr W to ask her to not say she was a member, but that she continued to do so on her website and CV. Dr W had passed her RCGP exam for this, but failed to apply to membership. SJ states there is evidence she did know she was not a member.

SJ asserts that in 2017 Dr W was suspended which meant that she was not allowed to continue prescribing prescription-only medication but she did anyway.

SJ says that Dr W omitted from her CV that she had links to Frost Pharmacy. She was sub-contacted to this pharmacy and so he says not declaring this was dishonest. Dr W said she stopped working with Frosts in January, but Dr Gale says they were engaged until May.

Dr W accepts that she didn’t inform Frost that she was no longer on the list. The GMC accepts that Dr W did not have a requirement to inform Frost, however SJ claims that Dr W should have kept them up-to-date.

SJ says that Dr Taylor became aware of concerns surrounding Dr W and recommended that Dr W status on the list should be reviewed asking should she be suspended pending the outcome of a hearing.

Dr Taylor produced a letter recommending an independent expert review about Dr W prescribing online.

The GMC were provided with a formal statement from Dr Jones stating he had been made aware of Dr W's online service being run without being registered. Dr W was convicted and fined £12,000

SJ states we are not here to debate the politics surrounding transgender people and that we must ensure that the wider health and wellbeing of the wider population - it's not about giving patients exactly what they want.

Adjourned until 12.30, we will hear from Professor Butler this afternoon.

Professor Gary Butler (PGB), from UCLH has just been introduced as the GMC’s first witness.

The panel and other members of the tribunal are being introduced to Professor Gary Butler (PGB). PGB is struggling with his video chat function.

SJ is asking Prof Butler about his statements. They are addressing his 1st statement which deals with PGB's experience with Pt A. The 2nd statement deals with PGB's experience with Pt C.

SJ asks PGB if he’s had time to refresh his memory of his statements. He says he has had sufficient time and confirms that the statements are still accurate to his knowledge. The hearing is now being adjourned for lunch. We'll be back at 2:05.

Dr Webberley’s representative, Mr Ian Stern, QC(IS) is cross-examining witness Prof. Gary Butler. IS states as they understand it there is one single provider - Tavistock - Butler agrees.

IS points to the NHS gender clinic services, questioning the protocols of the structure and how it works in practice. “UCLH do not have a gender dysphoria service.” IS asks is that correct
GB states that UCLH and the Tavistock are interlinked.

PGB says that whilst it is a subcontraction, “all of the consultations are done in parallel with The Tavistock. There’s always a member there.”

PGB states that the Tavistock is the only one of its kind in England and Wales. At the present time there are two endocrine clinics - London and Leeds but there are plans to expand.

"Why did Patient A travel to London to see you?” asks IS. Pt A was forced to travel from Leeds to London as they were the only centre in the country that could treat him, states PGB.

IS is questioning GB on his workload. PGB states it is accurate to say the number of patients being referred for gender-affirming care has increased globally. PGB adds that the service is constantly developing.

IS is talking about the UCLH website and trying to ascertain who else was working in gender care in 2016. IS wants the names of other practitioners from UCLH.

IS wants to know how PGB is registered with the GMC, what his specialism is in. PGB says he has dual registration, he is registered as a Paediatric Endocrinologist and that he’s done extra training for this.

PGB states he is involved with Great Ormond St and Tavistock - they are linked.

IS is saying that the increase in numbers must have has put great pressure on gender services. “There is a very large queue for endocrinologists,” says IS. PGB agrees but says it's important that they are diagnosed correctly.

PGB states that children are more likely to not be dysphoric than adolescents.

PGB tells IS that there is a long wait list for adults and children for gender-affirming treatment.

IS refers to the Care Quality Commission Report 2021. PGB says there are three CQC reports.

IS focuses on the Tavistock CQC report, he asks do UCLH and The Tavistock co-contract? PGB says they do.

IS refers to CQC doc as PGB has stated that Tavi and UCLH are interlinked. This document states that the service provided to the patients via the Tavistock is the only one of its kind in the country. PGB is now backtracking and stating that UCLH are not as closely linked.

A lot of backtracking from PGB. IS asks PGB, are you able to say that you have looked at any of the reports or material related to the Tavistock? PGB says he has.

IS continues to talk about the inspection of The Tavistock. PGB interrupts to say that he is not an employee of The Tavistock but he is an employer of UCLH. IS asks PGB does that mean he knows nothing about it then?

PGB disagrees and states that he works alongside The Tavistock but is employed by UCLH. IS asks PGB, “is this something you have knowledge of, or something you know nothing about?”

PGB states Patient A's referral that is included in the evidence as a good example of how full the referrals are when the endocrinologist receives a referral. PGB states that they take minutes of all of the referrals.

IS says what he is trying to understand is, was GB aware of Tavistock’s need for improvement? PGB states that there are questions raised as to how relevant this is on the CQC report as it was found that there is no duty of doctors to the patients on a waiting list.

PGB states it was an accident for the CQC to include this. IS states that the children waiting for help are at serious risk of self-harm.

PGB bats around the question as to whether he was surprised to hear that the people waiting for gender affirming treatment were struggling and he refuses to comment

IS says, "what I’m asking is, did the CQC assessments come as a shock.. or did you think The Tavistock was doing a good job?” GB goes onto to say that he goes through every patient carefully who is referred to him.

GB doesn’t see the relevance of the discussion and he doesn’t wish to continue this line of questioning.

IS states he asking these questions as PGB has written some of the NHS protocols. IS moves onto the review of the Tavistock services by Dr Hillary Cass. IS states that this review is taking place due to the issues found by the CQC but PGB states that he is involved in the review.

IS states the purpose of the Cass Review is to deal with the problems that have arisen from there being a single provider (Tavistock). PGB says he thinks that is one of the factors as to why they are doing the review.

PGB states that there should be local involvement in both GIDS and GIC because it is no longer containable within the specialised service.

PGB proposes more steps to reaching the gender clinics as a solution and states that every endocrinologist would be able to help a patient with gender dysphoria.

IS asks “even Paediatric Endocrinologists haven’t been sufficiently trained?” PGB says that they are well prepared to treat gender dysphoric children as they have a higher level of training.

IS says in 2017 PGB claimed to have over 600 patients with GD under his care. IS presents a document from 2018 stating that were are only 100 active follow-ups. PGB states he "doesn't know where that figure comes from" and stands by the 600 figure he gave the GMC.

IS is asking if PGB is aware of other clinics which are bigger than UCLH. PGB says he has a pretty good handle on them in Europe. “Is that the one you founded?” asks IS.

PGB states the treatments used in transgender are not unique, it is just that the application is different. All endocrinologists "would and should" be able to help a trans person go through the correct puberty for them but not all GPs would be able to.

PGB states the endocrine society produces relevant guidance from time to time and has encouraged WPATH to help with those guidelines. PGB states the guidelines were approved by many endocrinologists and organisations.

IS asked PGB would he say UCLH was the biggest clinic? PGB said yes "in the world" but then backtracked to "one of the biggest in the world" and settled on the largest in Europe.

IS draws attention to the NHS Standard Contract; GIDS- A Service Specification. IS asks, did GB have a hand in writing this? GB says he did along with lots of others.

PGB states he is very familiar with the document in question and confirms that it is the NHS standard contract for GIDS.

IS reads from it that GD can be more distressing during adolescents due to the development of secondary sex characteristics and increasing "social division between sexes" which can lead to increased risk of SH and trauma. PGB agrees it is a good description.

IS reads from the same document which states, "there has been some debate as to the minimum age for cross-sex hormones". There is some confusion between PGB and IS as to what 'gender assigned at birth 'means.

PGB states that they don't fully understand what makes someone trans but in the vast majority of cases the gender assigned at birth is correct. PGB states that it is more common that someone may be intersex than transgender.

IS asks PGB why he keeps referring to gender dysphoria as "very rare"

IS mentions that there have been differences in opinion about the age at which doctors feel it is appropriate to prescribe puberty blockers to children. He references the Bell v Tavi case.

PGB states that they regularly have audits but in the Bell v Tavi case there was a distinct lack of data available.

PGB states that no data has been published about those 18 and below taking Cross Sex Hormones (CSH). PGB says it is rare that an individual under 16 will have the capacity to consent to CSH.

IS asks if the problem is that there wasn't any triaging on individuals coming to GIDS. PGB says he used to triage the referrals to GIDS and the endocrine services. PGB states it is his knowledge that referrals are still triaged.

IS asks are some referrals to Tavistock are more urgent than others. PGB agrees there are. Puberty Blockers can now be considered for those under age 12 so long as they have reached tanner stage 2 says the NHS contract, PGB agrees.

The NHS contract states that so long as the criteria is met then PB can be prescribed by the patient's GP through a shared care agreement.

PB can be taken for a short period of time, PGB agrees they are not intended for long term use. CSH can then be introduced after the suppression of puberty.

Asked by IS about unlicensed medication, PGB states it is common practice to prescribe and use unlicensed medication.

IS asks is prescribing between Tavistock and the patient’s GP? PGB says it’s a shared care partnership with GP.

IS draws attention to referral management where it states that new patients should be seen within 18 weeks of being referred, which is a target that hasn't been met for many years.

IS says with the waiting time for Tavistock is it any wonder patients outsource care? PGB requests that they leave this line of questioning and requests the council make IS return to the case surrounding Pt A. Council says no.

IS reads from the NHS contract: "The service does not offer shared care with private clinicians but some patients may wish to access care from a private clinic or medication online." PGB states there aren't many patients that move outside of the NHS services.

IS questions PGB as to if there are figures as to how many people move from NHS services to private clinics? IS reads from the NHS contract which states that those obtaining gender-related medication outside of the NHS are cut off.

Adjournment for a short break, back at 16.05.

Chair confirms that the documents re Bell v Tavi Patient A’s mother are now uploaded. Chair invites IS to continue with his cross-examination of PGB.

IS reads from evidence which states that as of 2019 the waiting time for GIDS was 22-26 months

GIDS didn’t provide age data as it hadn’t been collated. PGB says there was confusion and it was provided.
IS states that there were 161 patients referred for PB including one as young as 10 by GIDS.

PGB protests the use of the word experimental when referring to PB. PGB stated that there were plans to review whether some young people could start CSH before age 16 but it never happened due to the legal implications.

PGB states that PB should be used short term, but that if they were prescribed as young as 10 they would have to wait 6 years until they could move to CSH.

Evidence suggests that most patients that receive puberty blockers go on to taking CSH states IS, PGB clarifies this statistic sits at over 80%.

IS is raising the lack of data from Tavi. IS says at time of the Bell v Tavi decision there was no material/ data available.

PGB reiterates that it's common to use unlicensed medicine. Discussion is happening about how much longer they will need with PGB.

The hearing is adjourning now. IS will resume his cross-examination at 9.30am tomorrow.