Thread by @tribunaltweets

Good afternoon. This is @Jeeeez17 at Day 29 of the Helen Webberley tribunal where we are expecting continued evidence from Dr Dean. As I'm not a touch typist I will be adding tweets in blocks today rather than in real time.
We are expected to start at 2.30pm.

As previously: HW is Helen Webberley, SJ is Simon Jackson QC Counsel for the GMC, IS is Ian Stern QC Counsel for Dr Webberley, P stands for the Tribunal Panel and JD for Dr Dean.

To any new followers, please bear in mind that we as members of the public don't have access to the legal bundles on which much of the discussions are based.

And we're starting now with Dr Dean (JD)

Chair We’d like to welcome back to JD. IS is to continue his cross examination of JD.

IS: looking at pat A. Last couple of points, point 25 is hardly a Q but a statement.

JD: Agrees it is self evident what he didn't want to communicate. It’s a difficult position for a dr partic when prescribing meds when other drs arent aware that medicines are being prescribed.

Where there’s potential for another dr to cause harm. Also undertaking investigations. There’s an arguament that you shldnt be prescribing or shld seek consent from TG patients so that information is shared. Otherwise there’s the potential for harm to come to patients.

Discussion re points 27-30 and whether JD wants to comment further on his written evidence.
JD: In final sentence point I'm making is not that its not neecessary to make a state re capacity to consent. My intention was that once a GP established implied consent for antibiotics..

..this capacity remains. There is a need to establish consent for CSH w irreversible effects for the indication of GD.

IS: It's obvious every dr assesses capacity every time they see a patient

JD: Correct

Discussion about a Dr RW and whether this is a specialist from Chesterfield or another Dr.

JD confirms he got a date wrong regarding a consultation in 2017 when HW was no longer practicing.

Conversation re Pat B blood tests. JD agrees that a previously unseen medical record..

.. is easier to understand with the Aug 9th witness statement. Agrees blood test is a component of follow up but lab tests alone aren't a complete follow up, only a part of it.

Very important is a discussion on wellbeing, psychological state, physical changes. A blood test is not adequate follow up.

IS: "looking at pat B records" and reads out conclusions that start

"I assess HWs practice to be below the standard expected of a GP with a specialist interest in TG medicine"

IS: why below acceptable standard?

JD: If treatment is for harm reduction rather than definite treatment it would not be below the expected standard..

..Following gmc guidance it could be reasonable for reducing harm but if it's for the purpose of treatment for a diagnosis in a patient with these characteristics I would not expect a GP to prescribe testosterone"

JD: provided they comply with GMC recommendations or are prepared to justify to prevent a patient from experiencing harm or potential harm… that would be acceptable for a reasonably competent GP.

IS: refers to email from JD. Do you stand by this?

JD: I stand by it but as I'm not used to these proceedings will look at it again..[long look for the relevant paperwork but cannot find]

IS: re the 3 elements of 2016 guidance it doesnt explicitly say you cant prescribe but can in certain circumstances. GMC isnt proscriptive guidance
For under 16s you disagree with the GMC, guidance isn’t restricted to adults & harm reduction may be acting within GMC guidelines

JD: Yes, that's what I'm saying

IS: moving to Pat C on p114 of your report a no of issues are duplicated,
p121 para C assessment and examination in 2 sessions by Dr K and one by HW:
testosterone not to be prescribed. We can see a no of recommendations/measures

JD: The way the examination is documented is unfamiliar to me but adequate information is present once I understood the method better.

IS: report copied to GP (point 38) so GP had the relevant information, but the report from HW isn’t included.

On 9 Feb consent form is signed. You didn’t think fertility was covered but you’ve now seen where it is?

JD: Yes

IS: GP wouldn't enter shared care plan. Blood test prior to prescribing so all is in order.

JD: Yes

IS: I have seen this re sharps disposal and the nurses email re dealing with sharps

JD: Yes

IS: April 30th 2017 prescription for a max of 9 days. It's impossible to do follow up after this prescription?

JD: Yes I'd accept that it’s impossible.

IS: Is there a reason you have Jan 17 on the letter but in fact it's dated in error. It should have been Aug.

JD: thank you for pointing it out but it's not an error on my part.

[off to catch my train now...will continue asap]

IS: One problem is that as we look back, the tribunal is aware of this, on p76 you’re given a number of statements re patient A and Dr Ws notes. It’s hard to know what letters to GMC from Dr W. Plus her response to ? Dr Reinhardt plus Dr Ws opinions of the treatment of patient A

IS: This is what you had to go on. It’s hard with what you were given. IS: moving onto 2021, and again it looks like a lot of documentation (letter of instruction) and HW p89: There’s 1412 pages of documentation of which approx 630 pages are redacted so you had to work through...

..a lot of black pages. Also, 230 of these relate to the California guidance and 30 to another guidance document.

IS: But you did not receive the report of Dr Ollsen-Kennedy?

JD: No

IS: Did you read Dr Tinners (?) letter?

JD: Yes

IS: but you didn’t have the material from patients and organisations dealing with their treatment, either via the NHS or Dr HW?

JD: I do not recall seeing other comments, no

IS: can I please have a couple of mins to check i haven’t left anything out?

P: Yes [no further Q]

P: thanks IS. Next we have cross examination by SJ. Over to you SJ

SJ: Want to take you back to beginning of your evidence, to questions from last week when we asked about your own route to becoming a GP w specialist interest in TG health, esp adults.

SJ: Didn’t consider yourself an expert in 2000? You had no formal training and at the time there were no other training options. Take me back to that time, compared to later on.

JD: Yes, so when I was first approached by Dr Hall to look after the service he’d started, there were 7 clinics in England. All of these had arisen from individuals who’d seen need for services. There was no formal training pathway or curriculum, publics and an..

..emerging professional society in North America, H Benjamin, that later evolved into WPATH. This focussed on North American practice but was written with relevance for the whole world. I’d seen a number of patients with GD in 10-15 yrs, all under the care of London, and...

..had been working in sexual health for some time so comfortable discussing these types of issues. Started working in this area 15-16 yrs before these events [being assessed at tribunal]
Options included sit in on experts consultations or do an apprenticeship...

..But this wasn’t universal nor expected. I’d worked with a psychotherapist in Newton Abbott for several yrs.
Then I had an interest in training and professional development, organising training programmes in sexual health medicine, did presentations and had discussions..

..with people working in the field.

SJ: Did you meet with other specialists? Was this in sexual health medicine? What do you mean by met them?

JD: So part of the learning programme for sexual health medicine had phone and email contact prior to educational training on gender identity development and GD. And also talks from surgeons working with GD, on a 2 week residential school held every year in Oxford...

..I also continued with my own personal study. But there wasn’t an opportunity to work in the service as a trainee, much like when I started in general practice there wasn’t a structured training scheme and certification.

SJ: So when did this multidisciplinary two week training programme, ie relevant, start?

JD: 2007 was the 1st course in Oxford which has run every year since, exc for the pandemic. Betwn 2007-14 I put the prog tog. Prior to that it was included in other progs eg sexual medicine.

SJ: tell us about the course.

JD: It was appropriate for GD endocrinologists, sexual health, neurologists [?], physicians, nurses, psychologists; not just covering surgery but also the development of gender identities, GD, and intersex conditions which are a source of...

..patients seeking help with GD as well

SJ: So from 2007 onwards there was a course. It wasn’t its prime focus but GD is an important aspect of it

JD: Yes

SJ: What else was available for those interested in TG health?

JD: I’m not aware of clinical training opportunities apart from those organisations with individuals, altho WPATH began some in 2013 then started global ed training. It was originally offered for partic health management training but others could start from 2014...

..Biannual meetings of TG health medicine, including speech and language therapy and lived experience. Callen Lorde also offered training - ran courses for GPs and others.
I can only speak for Exeter but we contributed training x3 a year for GPs and other colleagues.

JD: I’m sure that other areas would offer similar as well. Also GPs and others would spend a day to a fortnight with us learning. Certainly from 2005 onwards in Exeter, but probably from earlier than 2005 for older clinics.
That’s an overview.

SJ: You met with other specialists? How did you meet them? Were you focussing on GD? What was the purpose of these meetings?

JD: partly my own education but primarily to organise learning opportunity for colleagues. I’ve been involved in training on sexual health going back to probably 2000. I met international colleagues from online forums and corresponded with them.

JD: Kevin Wiley of Sheffield helped and introduced me to colleagues including ?? from Berlin who became a regular speaker at the Oxford conference. A network of colleagues probably started in 2012/3 in UK and our organisation/ association from 2014.

JD: It’s unfortunate it took so long to get a collegiate association established

IS: Do you mean BAGIS?

JD: Yes

SJ: You were asked about the Royal College of GPs learning resource?

JD: It was a learning resource and very helpful for GPs to help them work with a specialist service, to collaborate. My recollection was it was intended as an introductory module for those unfamiliar with TG...

JD: ..healthcare. Covering cultural sensitivity, epidemiology, understanding the experience of being gender diverse and different from others, minority stress, internalised transphobia.

JD: It gave an overview of the care pathway for those experiencing GD, including self care and professional treatments eg speech therapy, medications. It covered the goals people might want, depsychopathologisation ie that it isn’t a mental health condition.

JD: They may experience more MH problems but this isn’t a MH disorder but reflects how they are treated and acknowledged by society. Also the purpose of hormone therapy, the principles of initialising, monitoring and safety of treatments.

JD: It didn’t cover in any detail patient assessment, endorsement of being ready for hormones, or eligibility. It contained a list of resources, why guidelines were developed.

JD: This was the adult package. There’s also a child and young people module but this isn’t my area of expertise as a gender specialist although I do have some insights into training needs here as a GP.

JD: Both would take less than an hour to complete online and have no assessment at the end. I thought they were good as there’s very little else.

The University of California (San Fransisco) guidelines were the only other information available, although the difference in..

JD: ..practice with UK guidelines mean that they’re not really applicable to UK practice

SJ: Did it cover referrals, for children and young people with GD?

JD: I don’t have a copy of it so am working from memory. The adult document made it very clear that patients with GD shld be referred to a GD service rather than MH service for screening & that referral shouldnt be delayed as access is difficult ie make early referrals for adults

JD: I can't remember exactly but I’d be very surprised if young people's guidance didn’t make the same recommendation.

SJ: Are u able to continue for another 15 mins?

JD: Yes

SJ: you mention WPATH and you were asked about your membership. You’re not a member now though. What are your reflections on your membership?

JD: I was a member for 7 yrs I suspect. Certainly at the time of the Bangkok conference. It’s only an oversight that I’m not a member now

JD: I respect the organisation and urge people in the field to participate, as well as the UK organisation

SJ: 2016 was the Amsterdam meeting

JD: Yes and Bangkok was 2014

SJ: Did you attend the 2018 meeting?

JD: No, it was in South America and given the costs to the NHS when by that time we had a UK organisation. I’d self funded Bangkok and Amsterdam. I would have loved to go to S America.

SJ: You certainly attended HWs paper at Amsterdam [2016]? Do you know if she did a single presentation?

JD: I think she did 2 presentations although I didn’t see both of them

SJ: I’m going to ask you to...don’t want to run over...to look at d44

JD: Can you please read it out?

SJ: As there are 2 or 3 refs I want to take you to I’d like you to find the paper [JD sent an electronic version]

SJ: manuscript p13 is correspondence re awareness of HW prescribing CSH. Is it your recollection that you produced this correspondence?

JD: I remember my confusion as the first page seemed to be my email but we sorted it.

SJ: Was this put forward by you or by someone else?

SJ: Can you help with redactions?

JD: this didn't arise from me but I suspect it comes from NHS England

SJ: In 11 july email Aston Healthcare Ltd [might have been blocked out?
]
JD: It's a private hospital that provides feminising gender surgery

SJ: [re names blocked out] Nottingham HC Foundation Trust? Is this a mainstream trust or a GIC?

JD: I don’t know who has been blocked out

SJ: Re missing signature

JD: I suspect its one of the 2 surgeons but its not me

SJ: Look at p25 your email of 15 Aug 2016 where you deal with HWs recent presentation. She did not purport to be a gender specialist but an experienced GP with expertise in gender and sexual health.
In what capacity were you writing that she’s not an expert?

JD: I can’t remember

JD: She introduced herself as a experienced GP with expertise in sexual medicine and HRT. She didn’t say I’m a gender specialist. That’s what I was meaning to get across.

SJ: She appeared to be prescribing for harm reduction consequent to problems of access to NHS GIDS?

JD: this is what she presented to us. The purpose appeared to be prescribing for the purpose of harm reduction for those self medicating, potentially self medicating or those unable to access GIDS treatment

SJ: If she’s prescribing solely for harm reduction she wouldn’t need to be a gender specialist. Did she say she was prescribe for adults or also young people?

JD: My recollection is this only referred to adults. Seemed informative and consistent with my understanding of GMC guidance. She did not give a comprehensive overview of her practice.

P: We clearly aren’t going to finish with JD today. Can he return later in the week?

SJ: JD is returning Thurs morning I understand?

JD: That is correct sir

P: Thank you. I think we’ll have a full Fri.
Thank you for attending and offering to come again on Thurs.

P: We'll need to decide with the GMC about also attending Thurs afternoon.

IS: Asks for the name of the Oxford course

JD: It's name is the European School of Sexual Medicine Sir

SJ: Have we asked re Thurs pm? We don’t know if he’s available.

P: Thurs could see his evidence finished which would be excellent. No witness evidence on Weds after some housekeeping in private

P: Any other public things to sort today?
None.. session moves to private at 16.07

Returning 10.30am on Thurs