Thread by @tribunaltweets2

Good morning & welcome to the misconduct hearing of Dr Michael Webberley.
The tribunal rejected MW's 2nd app to adjourn & the tribunal will start and continue for 10 weeks.
This is @Wommando tweeting from Manchester.

Catch up: threadreaderapp.com/thread/1506977…
bit.ly/3qFSa1w

The GMC counsel are Simon Jackson QC (SJ) and his junior Ryan Donohue (RD).

RD was the GMC counsel in Dr Adrian Harrop’s case last Oct.

MW hasn't retained his counsel & may be representing himself.

The counsel are attending online & the 3 tribunal members are in person.

Abbrevs:
GGP: Gender GP
GMC: General Medical Council
MW: Dr Michael Webberley
HW: Dr Helen Webberley - (her tribunal reconvenes 4 April)
MPTS: Medical Practitioners
Trib: Tribunal Service Tribunal
VE: Voluntary Erasure
Chair: one of the 3 panel members leading

We were due to start at 9.30 and I'm currently waiting to be told when I can go in.

The clerk has informed me the trib has not started yet and they are busy printing out documents but it shouldn't be too much longer before we begin.

We begin.
SJ and RD are attending via remote access. Chair apologises for late start but a no. of docs had to be uploaded and printed off. The Chair confirms these with SJ.

SJ: I think the formalities that once MW number has been dealt with we're ready to go. In regards to docs, the factual matric and chronologies are as outlined as preliminary stage.

SJ: The docs are not agreed and goes without saying that reaching stage 1 determination the Trib will rely on witness statements, expert evidence, etc. It's important this Trib is only concerned with actions and conduct of MW.

SJ: There's ref. to another doc as Doctor A, you should not concerned with that doc. Only MW actions are the focus.

SJ: Dr Quinton has been spoken to and arrangements are being made for him to be able to deal with Qs and answers via direct contact, similarly Dr. Keirans. The absence of MW must be addressed to satisfaction of this tribunal.

Chair: we are only too aware we are concerned with MW alone. We will decide with ref to evidence we hear in these proceedings. Of course docs that have been provided are no less than working docs, but not in of themselves evidence.

SJ: one doc I didn't refer to is the supplementary guidance and a combo of international guidance and published in relation of support and treatment of TG patients. MW needs to be looked at as to what the global guidance says.

SJ: This is an issue raised by MW and GGP. That guidance, not every piece, is the principle framework that GMC says your entitled to look at and deal with as you see fit.
Chair: Is this guidance specifically referenced in experts reports?
SJ: Some but not all.

SJ: the court of appeal has addressed 'consent'. There is Gillick and that is an issue part of the general background.
Chair: Do proceed.

SJ: Because he's absent, prior to retirement, MW was exp. Constant physician and 34 years in NHS. He may well still be a fellow of Royal physicians. A CV of MW quoted himself an independent medical practitioner. At a time when he was this he'd have been working within NHS

MW: The Trib will have to make the the distinction between provision of care in primary sector and the referral system of private consultant involvement. In 2018, MW described himself as a 'gender specialist' and consultant. We see it repeated (takes to bundle)

SJ: this is an email from July 2018 from MW, he has his qualifications and his address and relating to GGP. He's writing to a GP about a patient who wanted treatment. In w018 MW was retired, engaged in providing medication via online vehicle GGP.

SJ: He says 'I'm a consultant physician specialising in TG care... Our services adhere to GMC guidelines... We have MD teams giving counselling and hormone prescriptions.' (Reads more too fast) MW gives GMC guidance and you will have GMC guidance in the Bundle

SJ: You can see in terms of education MW qualified in 1982 from Uni of Dundee. 1985 became member of RCP, MD in 1992 and fellowship in 1998. The relevance is competence. Was MW competent to be prescribing hormone treatment to TG patients?

SJ: in terms of charges, the first relate to MW in prescribing hormones called 'BMH' (Balance My Hormones)...back in Oct 2018. These concerns were reported by another Dr who ran Men's Health Clinic. This doc advised GMC whose care had been referred to him by MW/BMH.

SJ: MW told GMC the report was made because the reporting Doc was biased against him. Serious concerns have been raised about MW a) no physical meetings b) prescribed with no assessment

SJ: Dr Quinton CV is set out, in his BMH, he highlights serious clinical concerns regarding 18 patients, failure to conduct consultation before prescribing where GMC would submit clear lack of indication being written by MW.

SJ: Dr Quinton (DQ) further found prescriptions were delegated to non trained members of BMH staff and said written docs contained dishonest statements.

SJ: This is from an individual, won't read his name, dated 2017, copied into MW email and it's to the patient. 'It says it was nice speaking to you about Testosterone Replacement Therapy'...signed off by MBA and describes himself as 'Director/Facilitator'.

SJ: Here again we're dipping into the kind of exchanges between patient and facillitators of admin team. We can see client name, date, testosterone levels, MW is referenced, sometimes not.

SJ: We can then see so much more going on, and how this process of engagement and how they're being provided and to what extent MW is the driver and controller of that. DQ found MW conduct seriously below expected standard.

SJ: DQ summary opinion 'TRT is only ever indicated in male hypergonadism, details how it should be approached and reached. Remote prescribing raising concerns. Online questionnaires in no way permit the diagnosis of Hypergonadism.'

SJ: DQ explains why physical exam is important, DQ has reviewed MW for the 28 patients he treated.in all but 2 MW had not met patients or via video line. MW was routinely diagnosing hypergonadism in men.

SJ: DQ goes on to say possible reasons why these men had come with normal testosterone levelsand
MW failed to note mental health, Testosterone abuse, self esteem and punishing exercise routines.

SJ: The questionnaires dictated what patients should be prescribed. MW failed to take full medical history of patients. DQ says this lack of info gathering further compounded the info vacuum and he didn't inform patients GP. He was entirely reliant on patient.

SJ: DQ said MW lack of Clinical examination fell seriously short of expected standards with someone of his position.
DQ says doses of Testosterone were too high compounded risk of MW treatment of the 25 patients. MW had been rubber stamping treatment plans.

SJ: (reads out BMH info which says its an advice service) DQ also says prescriptions by MW were used by body builders rather than what would be provided for patients with hypergonadism.

SJ: MW compounded by introduced further drugs to counteract side effects rather than stopping medication fully. DQ says MW crossed the boundary by 'stacking' prescriptions.

SJ: (discussed dangers of testosterone) Men who abuse T readily share their strategies online including loss of testicular volume, regular volunteering to give blood to bring down levels...

SJ: DQ says MW vastly over prescribed testosterone compromising shrink of testes, over development of breast tissue, reduced libido and bone density...MW rationally believed he could outsmart the hypothalamus

SJ: DQ adds MW has a) failed to review patients b) failed to respond to lab results or side effects c) Clinical conduct feel below standard expected d) website constructed to discourage patients telling GPs, e) didn't communicate with patients and no contact at all

SJ: In terms of record keeping notes DQ notes MW fell seriously short, for 7 patients no evidence of care provided was kept. MW failed to obtain adequate consent for patients.

SJ: MW consistently failed to countersign patients, A cornerstone of good medical practice and integrity of doc/patient relationship.
I think we'll spend most of the day going through this opening so it's up to you to divide the breaks up

Chair: yes we have come to a convenient place
(Tribunal member addresses typo in the docs and it is resolved.)
Chair: We resume at 11.30
SJ: We're about 10% of the way through

We are back.
SJ: I'll pick up with the doc 'Care of TG patients'. As well as BMH, MW offered treatment via GGP. MW prescribed puberty blockers due to 'gender variance' and 'cross sex' hormones now referred to as 'Gender affirming hormones'.

SJ: the tribunal may be assisted with how TG medical care/gender dysphoria has developed in this country. The GMCs approach is in no way to question the right to access medical treatment.

SJ: The position is that the treatment they receive is by a reasonably competent gender specialist.

Gender dysphoria must last at least 6 months, a marked incongruence between, a strong desire to be secondary characteristics...

SJ: strong desire to be of and treated as the opposite Gender,
has typical feelings of opposite gender. Gender dysphoria is no longer to be regarded as a mental disorder. GD was previously GID to reduce stigma with gender variance.

SJ: With children the stages are:
Of children at least 6:
Impairment lasting 6 months
Strong desire to be other gender
Strong preference to wear clothes typical of opp gender
Strong preference of behaviour
Strong dislike of secual anatomy

SJ: Strong desire to exist as experienced gender.

Shouldn't be viewed as illness and does not always require treatment.

For TG, gender queer and non binary there are 3 distinct phases to achieve desired GI:

SJ: 1) puberty blockers appropriate for tanner stage 2+. In natal girls this is beginning of breast and boys scrotum gets larger
2) cross sex hormones (prescribed at 16)
3) gender reassignment only available to 18+

SJ: The principle of consent is of considerable importance. Adults can consent from 18, subject to info provided. Children over 16 are seen as lawful to consent and parents may consent on behalf of children under 16.

SJ: The patient must evaluate benefits against uncertainties and unknowns which may have huge impact on them in future. Some very young patients may find themselves undertaking this balancing exercise with great difficulty.

SJ: Puberty Blockers often described as 'time to think' medication and reversible. Context of a young patient about to embark on puberty becomes distressed and they reject it and how that psychological and social issue is to be resolved.

SJ: in the anxiety of the dysphoria the child may be making a a decision about irreversible blockers, the potential of that decision will have serious impacts on fertility.

SJ: We're going to spend time going through the guidance and the evolution of the guidance. Partic with recent developments in the UK.

SJ: in terms of evolution of guidance, in 2006 the Amsterdam gender clinic published a protocol....noting two elements are the psychological and paediatric encrinology. Was MW able to deal with these aspects?

SJ: Also the guidelines for TG and NB people published in USA, 2016. Going back to 2006 paper, the first diagnostic phase info 'must be obtained from child and parent. The child is seen by 2 team members and psychiatrist.'

SJ: The relevance is to put into context as to what is set out in broader guidance and when we look at the way MW has (or not) gone through the assessments and diagnostics.

SJ: 'fully reversible' and 'partially reversible' you have set out there, the 'partially' is significant. Adolescents eligible for cross sex hormones are 16+.

SJ: (reads from bundle) MW dealt with children and adults. In March 2008, the NHS issued guidance to GPs and Health professionals for gender variant ppl. 'GPs are usually at centre of TG patients.

SJ: Sometimes GP may develop special interest in Gender and may be able to provide treatment. I'd suggest MW would say he was the latter.

SJ: 'GPs acknowledged as gender specialists can provide treatment locally' the assement may be carried out by GP, if not should be referred to gender specialist.

SJ: (reading) 'Treatment for gender issue should not be delayed'. Its identified those who conduct assessments should focus on GD and any other conditions, eg, psychiatric.

SJ: 'hormone therapy can be given once gender dysphoria is diagnosed.

(Reads) a natal female, before developing breasts, the commencement of blockers prevents breast growth.

SJ: As an experienced tribunal the area of consent is nothing new, what is new is the ages of the patients able to consider this treatment.

SJ: Whilst MW in email to GP saying 'we have all of these skills within our MDT' when we unravel it all it's whether those ppl were going through the necessary steps.

SJ: then we have endocrine report says give puberty blockers until 16 when cross sex hormones can be introduced. In some circumstances, a child is put on puberty blockers at 12, then continue until they can address the issues and consent

SJ: further info 'sex reassignment requires expert MD treatment. The individuals must distinguish between GD, GID and use appropriate interventions. Should be trained in child and adolescent health

SJ: (referencing WPATH) the following are minimum credentials for ppl working with children present GD: trained in Child and adolescent psychology, what credentials did MW have in this?

SJ: An important one 'continuing education, this may include meeting, webinars, seminars, participating in research', had MW undergone any of this?

SJ: DQ observed that 16-18 lie between paed and adult, in respect to their GD are rooted in the paediatric sphere.
MW undertaking this.. while being retired is at risk of being invalidated

SJ: A number of other example when you're 16/17, they're seen as having capacity. Principle underpinning adults, DQ says it is more straightforward.

Clinicians can have far greater certainty of DSDs and there's no puberty to be blocked.

SJ: The use of analogues is used as a reserve despite cross sex hormones. Eg, when menstruation hasn't been suppressed in trans males.

SJ: DQ says before prescribing hormones:
1. Diagnosis by specialist
2. Info of risk
3. Regarding improvement to GD, it should be understood hormones don't treat all psychological symptoms
R. If MH diagnosis, disturbance must be looked at regarding consent

SJ: when a patient is contacting MW through website, one must ask if MW asked adolescent's GP, or if there were CAMHS or social services engagement?

SJ: Guidance given by GIDS, in 2014 NHS Eng issued a specialised service circular regarding prescribing and monitoring GD treatments.
There is this about primary care ' GP's also have integral role providing people with GD, should work with clinics so they have safe access'

SJ: And it looks like MW was acting as primary and secondary care.

There is GMC's guidance 2013 in your bundle, ehich states, when prescribing online there must specific experience and ppl must take responsibility for giving treatment and continually assess.

SJ: MW contacted GPS with the view of them prescribing the meds. When we look at GMC guidance that says 'take responsibility', on the face of it does not comply with the medical practice.

SJ: 'You must give patients and parents/carers full info about meds you prescribe so as to make informed decisions'.

What is the evidence MW went through those processes identified by GMC guidance? The risks, benefits, limitations, formality of consent.

SJ: In regards to competence 'the decision requires high Specialised skills and presription of products outside this is not commonly general practice'. Where did MW stand in this framework?

SJ: The service is designed to give care to distress between 'natal sex and gender identity'.

SJ: The GMC does not set the age when medical intervention is not to be embarked on. It reflects the reality of each patient and provides framework which all doctors must follow. 'You must work in your levels of competence'

SJ: it is important this Trib is not about doctors prescribing puberty blockers and hormones, it's to be focussed on central issue if a doctor (MW) who had interest in Gender, was in fact competent and experienced enough to prescribe to TG/ GD patients without an MDT

SJ: important we submit MW did not have peer reviewed training and experience to carry out this role. Against that general statement it's important to look at treatment of patient V. V was only 9 when contact was made with MW.

SJ: MW should have advised with (missed) in prescribing puberty blockers to such a young patient.

SJ: We're now coming to what defines a specialist in TG medicine. Shall we break
Chair: we will resume at 1.40

@threadreaderapp unroll please