CMAGIC referrals

A: The CMAGIC pilot is a small-scale, time-limited pilot of an NHS Gender Incongruence Service in primary care. We are not accepting external referrals from primary care at this time. Your patient is eligible to use services at CMAGIC if they meet the following criteria:

• They are 17+, eligible for NHS treatment and registered with a GP in Cheshire and Merseyside

And

• They are on a waiting list for an existing NHS Gender Incongruence Clinic and are yet to attend the first appointment.

We are contacting eligible people directly to let them know about the service and invite them to transfer to CMAGIC as a service user. If your patient is not eligible to be seen by CMAGIC, a number of existing NHS Gender Incongruence Clinics will be able to accept referrals from primary care providers. You may also have the CMAGIC Trans Health service in your area. Ask your patient which service they would like to be referred to. Contact details and information for existing services can be found here.

CMAGIC works with its service users to undertake assessment for and diagnosis of gender incongruence (GI), as well as providing access to a number of NHS pathways and procedures known to alleviate GI and its related distress.

Subsequent to a diagnosis of GI, many of our service users may wish to undertake gender affirming hormone therapy (and anti-androgen therapy if appropriate). CMAGIC will initiate hormone treatment and its initial monitoring and titration, before making prescribing and monitoring recommendations to primary care clinicians.

Your patient will be asked to consent to information sharing between CMAGIC and the practice, will be able to share a range of online resources, and offer a dedicated telephone surgery for healthcare providers. Regular CPD opportunities will be available to ensure you feel confident in supporting your trans/non-binary patients and in prescribing for gender incongruence.

We also provide counselling, advice and referral for fertility preservation, speech and language therapy, and access to other gender-affirming pathways, including ‘top’ (or chest) surgeries, and ‘lower’ (or genital surgeries). As well as a varied programme of talking therapies and support options (including but not limited to psychology, social work, peer support and psychosexual therapy).

We aim to discharge patients back to primary care once they have received the gender affirming care that is right for them. However, our clinical support services such as trans health and telephone surgery for healthcare providers will remain open access to ensure general practitioners feel confident in providing on-going support to their trans/non-binary patients.

The responsibility for general practitioners supporting trans/non-binary people is largely similar to that of non-trans people. Primary care services that are of particular relevance to a person who is undergoing a medical transition may include:

• Updating and amending records as requested by patient (including their name and gender marker. You do not need to see legal documentation in order to do this and patients do not need to have undergone – or intend to undergo – any physical/medical interventions)
• Referral to weight management services
• Referral to mental health services
• Access to smoking cessation services
• Facilitating blood tests (although results will be interpreted by CMAGIC).

Other primary care responsibilities include:

• Prescribing and administration of medication (once initiated by CMAGIC and patient is stable)
• Taking bloods and undertaking monitoring of hormone therapy- although this may occur within Trans Health if available in your area
• Follow up care post surgery (including district nursing).

The General Medical Council have produced clear guidance for GPs who are supporting trans/non-binary patients in primary care, including advice on how to make your practice more inclusive, as well as your responsibility to take over the prescribing and monitoring of hormone therapy once a person is discharged from an NHS Gender Incongruence Clinic. See the GMC’s guidance on Trans Health.

Gender Incongruence Clinics and the gender affirming services and procedures that are accessible via their clinical pathways (e.g. speech therapy, some surgeries) are centrally funded by NHS England’s Gender Incongruence Clinical Programme (which falls under Specialised Commissioning).

Currently the funding of the majority of gender affirming care via the NHS is not the responsibility of local CCGs (including assessment, diagnosis, gender affirming surgeries, specialised talking therapies). However, when a person is discharged back to primary care after completing their pathway at a Gender Incongruence Clinic, prescribing and monitoring of hormone therapy (and its funding) becomes the responsibility of primary care, this may be delivered via the Trans Health service if available in your area.

Further information about the Gender Incongruence Clinical Programme is available on the NHS England website and GMC guidance for General Practitioners is also available online.

It is our responsibility to discuss fertility and reproductive health as part of the CMAGIC pathway, particularly if people are interested in hormone treatments or surgical procedures that will impact their fertility. However, we do not provide fertility preservation, gamete storage or fertility treatments.

Funding decisions about storage and fertility treatments are made locally by CCGs (some will fund these procedures whilst others do not). For more information about fertility preservation and treatment for trans/binary people, see the information for patients provided by the Human Fertilisation and Embryology Authority.

Waiting times for existing NHS Gender Incongruence services can be in excess of two years, from referral to first appointment. In that time, nearly 25% of those waiting may decide to access unprescribed hormone therapy from various sources. There are a number of ways in which GPs can minimise the harms posed by long waiting times and self-medication, as advised by the GMC and the Royal College of Psychiatrists:

• Do your best to understand your patient’s views and preferences and the adverse outcomes they are most worried about
• Speak to them about the risks of self-medication
• Explore abridging prescription to minimise their risk of adverse outcomes
• Refer to the Trans Health service if available in your area
• Undertake monitoring of hormone levels, FBCs and U&Es
• Advice and support smoking cessation

Click to view the GMC’s full guidance on Bridging Prescriptions.

All patients are entitled to change the gender marker on their patient record by request at any time. They are not required to provide documentation (e.g. a deed poll or Gender Recognition Certificate), nor do they need to undergo any form of assessment, diagnosis, or medical procedures in order to do so.

It is important that practices are aware of the steps that need to be taken when a patient changes gender. Following the process will ensure continued patient care and ensure there isn’t an impact on your practice payments.

A step-by-step guide of the process is detailed on the PCSE website.

Trans patients have a legal right to change their name and gender on their NHS records at any time and may bring a civil suit against practices that do not accede their request.