Read standard 3: Collaborative leadership and governance

Standard statement

Organisations demonstrate effective and collaborative leadership, governance and partnership working in the planning, management and delivery of gender identity healthcare.

Rationale

Effective and collaborative leadership and governance are critical to promoting an inclusive culture and supporting people to access gender identity services. Organisations should incorporate Realistic Medicine principles when delivering services including value-based medicine, shared decision making and trauma informed practice.⁶, ⁷, ²¹, ²²

Good clinical and care governance includes adverse events management, whistleblowing, escalation procedures and robust data monitoring.²³-²⁷ Governance structures should demonstrate clear lines of accountability between NHS boards of treatment and residence, and for multi-disciplinary and multiagency working.

Services benefit from clear multidisciplinary and multi-agency pathways and protocols, which are evidence based and informed by current practice. Organisations should implement the relevant national policies, frameworks and other related guidance.¹ Organisations should ensure they have sufficient staff capacity to facilitate person-centred care and support on a timely basis at all stages of the clinical pathway.²⁸ Nominated lead clinicians for gender identity services should provide essential oversight and assurance. Organisations should implement National Waiting Times Guidance²⁹ across gender identity healthcare including specialist gender identity clinics.

Services should work in partnership at a local, regional and national level. This should be multidisciplinary and multi-agency, including primary care, pharmacy, independent healthcare providers, other public sector partners and third sector partners. Effective planning and partnership working should be underpinned by robust information and shared care arrangements. Continuity of care throughout the person’s journey or at key points in their life improves patient outcomes. This may include moving from a young person’s service to adult services or moving into a care home or supported accommodation.³⁰, ³¹

Where a person has to travel for care and treatment, there should be clear and accessible policies for the reimbursement of patient expenses and costs. These should be in line with NHSScotland policy.³²

Clinically relevant information, records and care plans should be kept throughout and shared as appropriate. Consent should be obtained in line with national policies and procedures. Information should only be shared with the person’s representative with their consent and in line with legislation and national guidance for example, child and adult protection policies.²⁵, ²⁶, ³³, ³⁴

Organisations should demonstrate effective planning, management and continuous quality improvement and assurance of these services. The collation, analysis and review of service and outcome data, including feedback from people with lived experience is integral to service design and monitoring.¹⁹, ³⁵, ³⁶

Who is responsible for meeting this standard?

All organisations and staff in line with their roles, responsibilities and workplace setting

Criteria

3.1

Organisations have an inclusive, rights-based and person-centred culture, which is demonstrated through:

supportive and collaborative leadership and management
value-based, compassionate and trauma informed practice, service planning and delivery in line with NHSScotland values and Realistic Medicine principles
routinely informing people of their rights.¹³

3.2

Organisations demonstrate robust clinical governance arrangements across gender identity healthcare pathways, which includes:

clear lines of accountability between NHS board of residence and NHS board of treatment and individual roles and responsibilities
a designated lead for adult and young people’s gender identity services
safeguarding policies and protocols
clinical and medicines management in line with evidence based guidance, protocols and best practice
a multidisciplinary strategy group for gender identity services, including lived experience and third sector representatives
effective partnership working across healthcare at a local, regional and national level
effective partnership working across service providers including independent providers.

3.3

Organisations have pathways in place based on current evidence and best practice to ensure people have access to:

gender identity healthcare
specialist gender identity services
other specialist services such as mental health or psychological support.

3.4

Organisations have processes to ensure people can access services close to home or the most accessible service for them, where possible.

3.5

Where a person must travel to access services, organisations:

have clear, accessible and fair policies for reimbursement in line with national guidance ³²
provide people with information about what is covered and support where appropriate
work with community planning partners to address transport barriers.

3.6

Organisations demonstrate a commitment to internal and external quality assurance through:

assessment of current service provision against professional guidance and national standards, including the Healthcare Improvement Scotland gender identity healthcare standards
undergoing scrutiny, inspection and regulation where appropriate to the service.

3.7

Organisations work locally, regionally and nationally to evaluate and improve service design through:

joint improvement work
facilitation of engagement and feedback from people with lived experience and, where appropriate their families/representatives
review and learning from feedback, compliments and complaints.

3.8

Organisations have a robust process for the reporting and review of incidents and adverse events, in line with national policy, which includes:

a standard and consistent approach to reporting
clear accountability and responsibility for local review and response
a documented escalation and incident management process
timelines for managing the process
processes for monitoring actions and learning from incidents and adverse events
processes for medicines related adverse events
long term monitoring of events
information and support for those impacted by adverse events, as appropriate.

3.9

Organisations have systems and processes to ensure adherence to national Whistleblowing and Duty of Candour guidance.²³, ²⁴

3.10

Organisations have systems and processes to demonstrate:

adherence to safe staffing legislation, building capacity and sustainability
a staff workforce plan including for specialist services where appropriate
compliance with professional and organisational codes of practice and frameworks
continuous quality improvement
a service specification for specialist gender identity services, where provided.

3.11

Organisations ensure processes are in place to support sharing of data and intelligence across organisations and services, which covers:

reporting, benchmarking and performance to improve patient safety, patient outcomes and quality of care
audit to ensure care is evidence based and informed by current practice
regular reporting to Public Health Scotland of specialist gender identity services waiting times, data monitoring and reporting requirements
information governance and sharing with other services in line with national guidance and General Data Protection Regulations.²⁵, ²⁶, ³⁴

3.12

Organisations ensure that care is delivered in an inclusive, safe, trauma informed and accessible environment, including waiting areas and consultation rooms.³⁵, ³⁶ Where the care is delivered remotely, or using digital tools, the principles of providing inclusive, safe and trauma informed environment still apply.³⁷

3.13

Organisations work in collaboration with national services and academia to collect and to share data as required to support national benchmarking and research. This will adhere to information governance and consent legislation and protocols.

3.14

Services and organisations work in partnership to:

provide continuity of care and support
share practice to support the development of local services with input from specialist services, where appropriate.

What does this standard mean for...

What does the standard mean for people?

You will experience services that are inclusive and rights-based.
You will have opportunities to provide feedback and participate in decisions about how services are shaped if you wish.
You will be supported by staff who staff work together to provide you with a high-quality service.
Information about you and your care, including personal data, will only be shared with your consent unless there are concerns for your wellbeing. This will be explained to you.
Organisations will share how services have been developed and improved because of your feedback.
If you need to travel to access services, you will be able to claim reasonable expenses.

What does the standard mean for staff?

Staff, in line with roles, responsibilities and workplace setting:

are provided with effective and collaborative leadership
encourage and empower people to share their views and experiences of services
are aware of how to report and escalate concerns, complaints or adverse events
work in line with clinical protocols, pathways, standards and guidance
share feedback to inform service improvements.

What does the standard mean for the organisation?

Organisations:

have governance arrangements in place demonstrating roles, responsibilities and lines of accountability, including adverse event management, incidents, compliments and complaints
provide safe, person-centred, consistent, trauma informed, evidence based and high-quality gender identity services
have workforce plans in place to support service delivery
embed the engagement of people with lived experience, communities and staff within service design and decision making, evaluation and planning for improvement
undertake quality assurance and improvement activities to ensure performance against standards
ensure compliance with data protection legislation, information governance, consent and safeguarding
promote, encourage and support research and audit activity, and ensure that collection, analysis and review of outcome data is a routine part of gender identity services activity
have clear and accessible policies for reimbursement of patient expenses in line with national guidance.

Examples of what meeting this standard might look like

Documentation describing lines of accountability, roles and responsibilities, escalation routes, incident and adverse event reporting and review.
Improvement work, data collection and review of data, including feedback from service users and staff members.
Multidisciplinary and multiagency working, including involvement of professionals, creation of care pathways and local standard operating procedures. This may include social work, education and third sector agencies.
Evidence of co-designed service plans, innovative engagement with local communities and good, inclusive communication with service users.
Action plans demonstrating implementation of national guidance or standards, including those produced by Healthcare Improvement Scotland.
Shared care protocols and memorandums of understanding between NHS boards, multi-disciplinary partners and services.
Evidence of inclusive service design including accessible clinical environments, access to gender neutral spaces.
Demonstration of expense claims information and support.
Specialist gender identity services have a service specification, including a staff workforce plan.