Read standard 6: Assessment and care planning

Rationale

People may engage with health services at different stages and for different reasons. People should be fully involved in decisions about their care, and where appropriate their families/representatives should be involved with consent.

A holistic, person-centred assessment is undertaken to ensure that people receive the care that is right for them. Assessments should be undertaken by trained healthcare staff who are responsive to the needs of the person and understand the services available. Referrals should be made in line with the relevant care pathway.¹, ¹⁵

Access to a multidisciplinary team, consistency of care and incorporating the person’s needs and aspirations supports the development of a personalised care plan. This ensures that people receive the care that reflects their needs and personal circumstances. Services should work in partnership to ensure that care needs are continually assessed, reviewed and monitored. The care plan should be shared with the wider multidisciplinary team, including the person’s GP and/or pharmacy, where appropriate. There should be clear communication between services, including transfer of care in line with local pathways.

Not everyone will need a referral to specialist gender identity services. Some people’s care needs will be better met in other services, including primary care. Some people may decide to halt or reverse aspects of their gender identity healthcare. An individual’s decision will be personal and a person-centred and compassionate approach should be taken by staff and services.¹², ¹⁵, ³⁵, ³⁸, ³⁹

Who is responsible for meeting this standard?

All organisations including NHS Scotland gender identity services and independent providers.

Criteria

6.1

Organisations have local pathways and protocols for assessment for surgical, non-surgical and other relevant services that:

have been developed in partnership with other services
define roles and responsibilities in the initial and subsequent assessment, monitoring and care planning
support continuity of care, for example having a named clinician
provide information on areas covered in the assessment
ensure the active involvement of people in decision making, and their families/representatives where appropriate, and where consent is provided
support shared care across services and settings.

6.2

Assessment at a gender identity service is undertaken by appropriately trained healthcare professionals, is comprehensive and holistic, and includes:

the person’s needs and what matters to them, avoiding assumptions about what support or treatment may be sought⁹
relevant existing or previous care and treatment plans
mental health and wellbeing
medical history, including co-occurring conditions
sexual health and fertility
capacity and consent in line with national guidance
need for further support and/or treatment
input from the family/representative with consent and where appropriate.

6.3

Organisations delivering gender identity services have protocols in place to ensure timely referral²⁹ to appropriate services covering:

fertility preservation
hair removal and wig provision
medical treatment including input by specialist pharmacists, endocrinology and paediatric endocrinology
mental health and psychological support
sexual and reproductive health
speech and language therapy
surgical services.

6.4

Specialist gender identity services have pathways and protocols to ensure the referral into the service is appropriate for the person. This covers:

review of referral criteria and appropriateness of referral
timely triage and referral to other, more appropriate services, including primary care and mental health services
supporting people to understand how their care needs are assessed, and which services will best suit their needs
partnership working with other services to minimise delays to the person’s care
how to work with the referring service and healthcare professionals to ensure appropriate referrals.

6.5

The care plans developed in gender identity clinics:

are co-produced with the person
provides a key summary of person’s initial assessment, any ongoing care and support needs
can be accessed by the person
are communicated across the multidisciplinary team including the person’s GP, pharmacy, with the person’s consent where appropriate
are regularly reviewed and updated as a person’s circumstances or needs change.

6.6

The organisation has transfer of care protocols when people move between care providers. This includes NHS services and primary care providers and people transferring from outwith the UK. The protocols should:

be person-centred
enable continuity and consistency in care
describe clear roles and responsibilities
provide clear criteria about maintaining the original referral date, where appropriate
set out key information required, to reduce unnecessary delays in the person’s care.

6.7

People who decide to halt, reverse or restart aspects of their gender identity healthcare are supported by knowledgeable and compassionate staff to:

discuss their needs
explore treatment, care and support options
access services which are right for them.

What does this standard mean for...

What does the standard mean for people?

You will be offered a comprehensive and holistic multidisciplinary assessment.
You will be supported to identify and achieve your goals and personal outcomes.
You will have a person-centred care plan, which will be reviewed and updated as your needs change.
Your care plan will be developed jointly between you and your clinician and will support you to meet your needs.
Your assessment will take into account your ongoing health and care needs and any medications you use.
Your care plan will be followed if you move between different services and NHS boards.
When you join the gender identity service from another NHS provider or NHS health board, your initial date of referral will be maintained.
You will be supported by kind, empathetic and knowledgeable staff.

What does the standard mean for staff?

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

can confidently complete a holistic needs assessment with input from the relevant specialties and other services
can develop, review and appropriately share a care plan
understand their role in reviewing assessed needs
work with partners across different healthcare settings, including primary care
support and enable people to make informed decisions about their healthcare
provide information on who to contact if an individual requires further advice, support and intervention.

What does the standard mean for the organisation?

Organisations:

ensure staff are trained in holistic needs assessments and person-centred care planning, including regular review of an individual’s needs
have processes in place for service transfer, which support consistency and continuity of care and demonstrate positive working relationships between services and other NHS boards or providers
ensure staff are supported to provide the right information, advice and signposting as part of care planning.

Examples of what meeting this standard might look like

Evidence of clearly documented assessments and multidisciplinary care plans.
Documented pathways and referral protocols for service transfer.
Individual and accessible transfer of care plans.
Evidence of supporting people to identify and monitor their own needs and choices.
Accurate and accessible information to support an individual’s decision making on treatment.