An independent patient safety investigation into concerns about inappropriate prescribing of medications for gender incongruence / dysphoria by some clinicians at the WellBN GP Practice has been completed.
It was looking at prescribing of medications to children under 18 that fell outside of NHS commissioned services, clinical policy and guidance.
Children and young people seeking support for gender dysphoria or incongruence on the NHS should be referred into specialist, nationally commissioned services.
Puberty suppressing hormones are no longer being offered for the treatment of gender dysphoria or incongruence outside of NHS-commissioned clinical research, and prescribing of masculinising / feminising hormones is currently paused pending the outcome of a public consultation on a revised draft clinical commissioning policy that would prevent their future use to treat children and young people.
This investigation, led by NHS Surrey and Sussex ICB with support from NHS England, was carried out in accordance with the investigation’s Terms of Reference.
Investigation outcome
The investigation’s findings support the concerns that WellBN GP practice was inappropriately prescribing medications to children and young people for the clinical indication of gender dysphoria.
Investigation findings [pdf] 1MB
As a result, it concludes that potential harm has been caused to the 78 children and young people who are within the scope of the investigation. Harm is defined within the Terms of Reference and relates to absence of care that should have been provided and the potential impact of the care that has been provided.
Key findings
- Overall, the clinical approach to care - including oversight by the GP Practice partners - fell far short of what could be considered safe or appropriate.
- The care provided to child and young people was not part of a commissioned NHS pathway of care.
- None of the clinicians whose care was considered in the investigation were professionally competent to initiate or assume responsibility for prescribing these medications without oversight or support from a specialist gender service.
- The investigation found an absence of advice or support from specialist clinicians, such as from:
- Consultant paediatric endocrinologists (doctors who specialise in hormones) in regard to prescribing medications
- Specialists in gender incongruence in regard to assessment and diagnosis of gender dysphoria or gender incongruence, and in forming individual care plans
- Paediatricians and mental health professionals in the broader assessment of children and young people with other complex presentations and developmental challenges
- Fertility specialists in regard to the impact of these medications to reproductive health
- Necessary physical tests (such as blood tests) were often not carried out, putting the immediate and longer-term physical health of your child and others like them at risk
- Wider concerns were also identified, including those relating to the Practice’s poor approach to clinical governance including badly kept medical records, and the approach for seeking informed consent to medical intervention.
Next steps for those in scope of the investigation
Gender dysphoria and incongruence require specialist care. Therefore, to receive NHS care and support, an individual needs to be under the care of one of the nationally commissioned specialist services.
If not already receiving care from specialist gender services, those in scope of the investigation will have up to the 31 July 2026 to consider whether to accept being referred to these services, or not.
If someone is 16 years and over, they will:
- be asked whether they consent to be referred to the specialist NHS Children and Young People’s (CYP) Gender Service (if 16 years old) or an Adult Gender Service (if 17 years and over), if a referral hasn’t happened already.
- be seen as a patient in the specialist NHS gender service. They will meet with the service, and they will assess their ongoing needs, including medication. They will work with them to agree onward care, including formalising any ongoing involvement from their GP, and will also discuss any concerns they may have about their physical health from any medication they have received. As commissioner of specialised gender services, NHS England has planned for everyone in scope of the investigation to be seen very quickly for your first appointment. This aim is that this will be by the 31 July 2026.
- once care is reviewed, there will be a relevant specialist recommendation. The specialist recommendation is to provide a formal diagnosis and form an individual care plan that may include hormone medication alongside other forms of support.
- in such cases, medication maybe prescribed by the GP under a detailed written collaborative care plan between the GP and the specialist NHS Gender Service that sets out, amongst other things, the Practice’s responsibilities in providing the patient with necessary tests and regular monitoring in the interests of safety.
If someone is under 16 years old, they will:
- be asked whether they and their parent / carer consent to be referred to the specialist CYP Gender Service, if a referral hasn’t happened already.
- if they consent, they will be seen by specialist NHS gender service who will assess ongoing needs, including medication.
The CYP Gender Service will not prescribe masculinising or feminising hormones to a child under 16.
Frequently Asked Questions for parents, carers and children [pdf] 186KB
Support for families in scope of the investigation
Every family is receiving a personalised letter sharing the outcome of their case note review, and recommended next steps for onward care and support, including prioritised referrals into specialist services. Everyone is strongly encouraged to take up their referral into the specialist NHS gender services.
Dedicated phone line
A dedicated information line for young people under 18, and their families, who are receiving gender care from WellBN. You do not need to be a resident of Sussex to use this.
If you have questions regarding how this investigation may affect you, or you need support because this news has upset you, please call. On this call, your details will be taken, and a support worker will quickly call you back at an agreed time.
- The number to call is: 0300 131 6775, then select option 3.
- This number is open 9am to 5pm Monday to Friday.
The support workers are NHS staff who are experienced in supporting young people and their families who are receiving, or who have been referred, to gender services.
Further mental health and wellbeing support
To help provide support during this time, we have arranged for specialist mental health support, the details of which are in the factsheet linked below.
Next steps
NHS England and NHS Surrey and Sussex ICB have jointly instructed the WellBN Practice:
- That it must not resume offering specialist gender care to children under 18 years and that the Practice’s public facing materials must make this clear with immediate effect
- That it must stop accepting children as patients from outside of its practice area unless there is exceptional clinical need that is unrelated to gender incongruence
- That it must stop prescribing hormonal medications to children under 18 years outside of NHS policy and guidance; a Children and Young People’s mental health offer from NHS services in Sussex has been made available to support children and their families where their medication is being stopped
- That it must comply with exceptional arrangements that will be in place for over the next year that will monitor its prescribing activities.
The NHS has analysed prescribing data relating to hormone treatments given to children under 18 among GP practices across the country and found that WellBN GP Practice in Brighton and Hove is an outlier. Further guidance to primary care has been published on the National CYP Gender Referral Support Service website.
A number of former and current clinicians at the WellBN Practice have been referred for the purpose of further professional investigation, both through their relevant independent professional regulator (the General Medical Council for medical professionals and the General Pharmaceutical Council for pharmacists) and / or through the NHS Professional Standards mechanism.
The GPs involved have signed Undertakings to not work with children under 18 years for the purpose of gender care while their investigation is ongoing.
The investigation report has also been shared with CQC, who have suspended the WellBN Practice’s CQC rating while their own assessment of the provider is underway.
If you have not been part of the investigation but have concerns about your care
If you have received care at WellBN GP practice but have not been in scope of the investigation, and have concerns about your care, please see the advice below:
- If you have received gender care at WellBN GP practice, please read a dedicated letter and share this with your current GP
PSI Letter for people aged over 18 [pdf] 177KB - If you are a registered patient at WellBN GP practice but have not received gender care, please contact us and our teams will come back to you.
Wider gender services in Sussex
To note, the Sussex Gender Service is unrelated to this investigation or the findings of the report. This service sits outside the scope of the investigation.