NHS England: Operational and delivery review of NHS adult gender dysphoria clinics in England (18 December 2025)

Summary

Commissioned by NHS England Specialised Commissioning team in July 2024, this operational review of NHS adult gender dysphoria clinics (GDCs) in England was led by Dr David Levy, with the support of a panel of clinicians and other key stakeholders. The aim was to determine whether the operation and delivery of the GDCs meet the requirements of the non-surgical interventions service specification and consider the safety and effectiveness of the GDC service.

Content

The report sets out its key findings as follows:

Access

A majority of these clinics have exceptionally long waiting times for NHS services, with patients often waiting for many years to be assessed. This can be distressing for patients, place undue pressure on staff and contribute to patient safety risks.

As the GDCs maintain separate waiting lists, the true size of the waiting list is unclear, as some patients may be referred to 1 or more GDC through self-referral or GP referral.

The current referral process means the majority of GDCs need to manage relationships with GPs and other services outside their region or ICB area. This places additional demands on resources.

Quality (including safety)

The absence of any patient outcomes data, alongside limited and inconsistent quality data reporting, and minimal clinical audit makes it impossible to properly understand patient outcomes and the safety of these services. These gaps place these clinics outside standard NHS quality assurance expectations.

In addition, existing patient demographic data and clinic feedback indicate that there has been a shift in patient demographics in recent years to a younger cohort with reported additional conditions. Yet, this has not always been met with corresponding changes in how some clinics identify and address patients’ potential additional biopsychosocial needs.

Productivity

There is currently a wide variation in service provision across the country. This includes differences in the number of appointments per GDC clinician and consultation length. These variations need to be considered both in terms of improving access and ensuring high-quality services and patient safety.

Additional financial resources have been made available to each GDC to expand its staffing in recent years. However, workforce data has not always reflected an expansion in staff numbers in some GDCs.

Culture, leadership and governance

Some clinics undertake little or no quality improvement work or knowledge-sharing between services. The senior clinical leadership approach at some clinics also limits staff’s clinical curiosity and the opportunities to identify ways to improve patient outcomes. 

The review also found that oversight by some trust boards and by NHS England regional specialised commissioning teams has not consistently identified these concerns, sought any mitigating actions or supported improvements.

This contributes to concerns that these services carry a high level of risk. Commissioners and host organisation oversight, governance and supportive leadership need to be strengthened to manage this risk. This will be critical to delivering improvements.

Next steps

Based on these findings, the review panel has set out twenty recommendations to improve patient care which are included in this report. The report calls for a wider healthcare response from national and local commissioning teams, adult gender dysphoria clinics, NHS trusts, ICBs, primary care, and other healthcare constituents. This joint approach will be driven by the proposed National Quality Improvement Programme for Adult Gender Services and a new National GDC Oversight Board.