Thread by @tribunaltweets

This is a summary of the closing submissions made by Mr Simon Jackson QC on behalf of the General Medical Council. This is not a verbatim record and should not be taken as such. I will post a similar summary of the closing submissions of Mr Ian Stern QC on behalf of Dr Webberly.

I will then post my summarised note of the legal advice which the Chairman Mr Angus Macpherson has provided to his fellow Panel members. This advice was the subject of detailed discussions with both parties' Counsel.

HW accepted that the standard by which breach of duty was to be assessed was the standard of a reasonably competent General Practitioner with a special interest in gender dysphoria. HW held herself out as a Gender Specialist and as an expert. This was the basis upon which HW

wrote to other GPs so that other GPs would look to her as an expert in the field. Tribunal must ask itself 1/Was HW competent to provide care for this cohort of patients? 2/Has HW provided an adequate standard of care? 3/Did HW's model of care provide an adequate standard of care

4/Did HW's standard of care meet the relevant standard namely that of a reasonably competent General Practitioner with an interest in gender dysphoria.

Amendment please : to "with a special interest in gender dysphoria".

These questions are judged by looking at the clinical consensus and the guidelines. GMC says these are the standards HW accepted for herself. HW must be judged by the then prevailing standards, not by hindsight and not by guidance which has evolved since. The relevant guidelines

were the WPATH (World Professional Association for Transgender Health) guidelines published in 2012 and the Endocrine Society Clinical Practice Guidelines for 2009.

Looking for consensus within clinical practice would involve at least referring to the key stages of good medical practice taking a history, examination, assessment, diagnosis, prescribing ( if appropriate), communication with other doctors, and referral when indicated. Noting

that HW departed from the above approach seemingly taking the view that these steps were not necessary or not indicated for these patients. HW asserted that it was not her role to question a patient's identity. GMC have never suggested this was her role but looking at WPATH

which advised making a psychological assessment before making a diagnosis of gender dysphoria and before deciding on the need for any medical intervention. HW took the view that this was not necessary and would delay treatment compared with "what the patient wanted". No doubt HW

had some experience but was she able to depart from guidelines in reliance on just that experience? It was accepted that the purpose of prescribing puberty blockers was to give a patient time to think. How long this time should be is a medical issue . HW was aware of this and

referred in her evidence to taking account of Patient C possibly being on blockers for 3/4 years. In deciding when to commence puberty blockers account had to be taken of medical issues ( bone density for e.g.) and also the psycho -social development of the child.

Sorry, have to drive home now. Back a.s.a.p.

GMC takes into account that Patient A's twin and sister were going through puberty - Dr Klink thought A could go through puberty later. No one could fail to be moved by the selfless care of A's mother for Patient A and the commencement of gender affirming hormones has had

positive outcomes. But this is not stand alone evidence that HW's practice complied with current good practice such as we could assure the GMC Panel that Patient A was not an outlier. This treatment is at the frontier of care for these very young trans patients. New heading

Training:all doctors are governed by a duty to maintain their competence and performance through appropriate training. SJ is referring to GMC published document "Good Medical Practice". Para 7 is about competency, how do you maintain it and how do you prove it.

Para 7 "You must be competent in all aspects of your work, including management, research and training", Para 9 "You must regularly take part in activities that maintain and develop your competence and performance", Para 14 "You must recognise and work within the limits of your

competence", Para 15 "You must provide a good standard of practice and care.... adequately assess the patient's conditions .. all patients ....where necessary examine the patient " HW is saying she does not need to carry out a physical examination - she is ignoring her duties.

Guidelines again - "referral as appropriate", Para 16 - in prescribing drugs or treatment to serve the patient's needs - and note that when assessing treatment to consider whether medication was the only treatment which would alleviate distress - medication think about whether to

prescribe or not and also the timing. Para 16b "provide effective treatments based on the best available evidence". That necessitated HW, before prescribing, to undertake a mindcheck and to ask herself "Before I do this - what is the best evidence in the best interests of this

adolescent." This involves checking the prevailing consensus and taking advice. It is a theme of HW's approach to say "There are no guidelines" ,but no, there was guidance, she could have spoken to people, there was a consensus - see the Guidance

Para (d) "consult with colleagues where appropriate". the GMC say that it is remarkable that HW did not consult with anybody else except her husband when she could have done so. Further duty " to check care is compatible" including where self prescribed or over the counter

medication is involved. What other treatments were in progress? In Patient A's case treatment was being provided by the Tavistock and this key issue should have been addressed. Look at HW's attitude to other providers - HW set herself apart from the mainstream of clinical care

HW says she followed international guidelines but note that the guidance she relies on re Patient A was published after the date of her treatment. In a young and rapidly evolving field prescribers must rely on experts. But there was no solid evidence for prescribing to someone as

young as Patient A. HW has been a successful advocate and the GMC rightly acknowledges this but this compassion has not been matched by her keeping up to the required standard. "No formal training" says HW. GMC says she could have sought this out. She could have sought help from

nearest teaching hospital in Cardiff. I asked her about this and HW said "You know I haven't done that". SJ I have to ask Why? Dr Dean spoke about opportunities for learning as did Dr Boumer (?) also although he was selective. GMC says apprenticeship provides good training - a

supervisor can look at your practice and guide/approve. Note that HW was entirely self validated. What did her patients know of her alleged training and experience? Of any further study? HW could have gone abroad. In 2019 HW went to the U.S. to a clinic run by Dr Olson-Kennedy

When asked about whether Dr O-K ran her practice on an MDT basis or not HW said she did not know. HW had set out from the start on seeking to set up an online service and to develop the techniques and methods for prescribing remotely. This concept is referred to in HW's statement

in her letter 31.08.2016 re a presentation HW was to give in Amsterdam- describes a proposed model which was different from the MDT approach. Ref to "task and finish" work being done and where Dr Dean was an onlooker but no evidence that HW's alternative would reach standard