User:Shadowchoir/Webberly

What this is: This is an archive of the livetweets of the Medical Practitioner Tribunal Services (MPTS) case involving Dr Webberley, a clinician working in the private gender healthcare company GenderGP in the UK. Source: The revelant Twitter page

In this case, and current tribunal hearing, Dr Webberley (Dr W) is accused of practising medicine outside the rules and regulations of the General Medical Council (GMC or GMCUK) during the period March -November 2016, A failure to hold a proper safeguarding policy, and (2018) a failure to be registered as a practice in Wales.

Day One:

I am here at the MPTS hearing for Dr Helen Webberley. The hearing has just started. Dr Webberley's counsel,  Mr Ian Stern, QC has stated that he has been provided with evidence late, without proper notice.

Dr Webberley is attending via video link. her connection is unstable which is delaying proceedings.

The tribunal chair is disclosing that he used to share chambers with Mr Simon Jackson QC, who is acting on behalf of GMCUK. He adds that they didn't see each other so it wouldn't be a conflict of interest.

The session is breaking so that the tribunal can read through the evidence. We'll be back at 12.

The session has resumed, the Chair is apologising for the technical issues and stating that the tribunal members have now read through the additional evidence provided.

Dr Helen Webberley's counsel Mr Ian Stern (IS) is stating that they were only recently made aware of some of the the GMC's evidence. He says that much of the GMC evidence is hearsay and questions the lack of expert witnesses from Tavistock.

Dr Webberley's counsel (IS) is referring to witness statements made by trans people. He says they are not testimonials as they provide background as to why these patients sought out Dr Webberley's help - because they were unable to get help from their GP or the NHS.

IS states that the GMCUK have the same access to GenderGP records as Dr Webberley has yet there have been no attempts from the GMC to access the actual emails from trans people. These emails detail people seeking help from Dr Webberley.

The GMC are questioning the relevance of the emails, IS states there is nothing to cross-examine as the emails just describe people's experiences and detail why they want to speak to Dr Webberley. IS asks why the prominence of the emails has been raised now.

IS says that the inclusion of the emails as evidence is not a disadvantage to the GMC, they demonstrate why Dr Webberley felt it necessary to act.

IS says mother of patient A made a signed witness statement to GMC in 2018. Her statement was included in the bundle. he says they cannot understand why she wasn't called to attend the hearing until May 2021.

IS has been in contact with the mother of patient A and she has indicated that she will be attending the hearing. She has submitted a draft witness statement.

IS says that there was a 3 year gap between GMCUK receiving the witness statement and contacting the mother of patient A. IS says that the mother of patient A also made a complaint about the GMC.

IS refers to a May 2017 witness statement from a lawyer whose child tried to access care through the NHS. They then went to Dr Webberley. In her statement, she says that Dr W prescribed for harm reduction. IS states that Dr W has the competence to provide this care.

The Chair has asked that the tribunal break for lunch. We will return at 2.05pm.

[tribunal resumes]

Dr Webberley's counsel, IS, is going through evidence they wish to submit, explaining why it should be allowed (as it is not testimonial). IS states that one of their witnesses backed out of testifying due to threats to her life.

IS says that Dr Webberley was in discussion with the GMCUK in 2017 about transgender patients and developing learning materials for doctors to upskill on trans healthcare.

IS is arguing for the emails from trans people to be included as evidence. GMCUK wants these emails discounted. He states that they evidence the torment trans people face when trying to access help to affirm their gender identity.

Re the emails from trans people, IS says, "These witness statements will assist you to understand the deep-seated feelings of individuals and what it means to have an incongruent feeling with your assigned gender".

IS is arguing for correspondence that was sent to the GMC from individuals to be included as evidence, he says they “essentially set out what is happening to their son or daughter- they are journey records as to the progress.”

Counsel for GMCUK, Simon Jackson (SJ), states the rules provide for the uploading of documents that are approved. He says that some of the evidence provided by Dr W's team is anonymised, redacted material which is hearsay and inadmissible.

SJ says that the steps that need to be taken to see if it is fair to admit the evidence is that the author must be contacted and check to see if it's okay. He says the GMC have had no evidence that these steps have been taken.

SJ says that the task of the tribunal is to look at different categories of material and decide if they are relevant & fair. He says it would be fair if they could see the whole document so they can see how the patients present themselves to a GIC or private service.

SJ and IS are discussing what is factual evidence and what is testimonial evidence. IS states that patient journeys are factual evidence.

Chair is questioning how realistic it is to obtain the documents unanonymised and unredacted. He questions if prominence is really an issue as they are from patients that Dr Webberley treated.

GMC counsel, SJ, questions whether the trans people providing witness statements can hold the opinions they do. He asks do they have the capacity to deem Dr W a competent doctor. He says there is a chance that these people no longer stand by what they say.

GMC Counsel, SJ, asks; should the authors of the documents be brought in so they can be cross-examined?

SJ states that he will accept the journey evidence from trans people, but only those without redactions as the redacted ones may need their relevance questioned.

SJ says non-redacted journey stories can be included if it can be proved they are legitimate and if “Dr Webberley can be asked about them.”

SJ says that the question is not did Dr W provide good clinical care to other patients, but specifically the patients discussed here. Having an unblemished record or a good character reference does not form a defense, he adds.

SJ is now discussing the admissibility of some of the evidence provided by the defense.

SJ is discussing the admissibility of evidence from a witness who is unable to attend due to fear for their safety. The GMC says they do not wish to admit evidence from someone who is unwilling to be cross-examined.

SJ says that some testimonials may be relevant in stage 2 of the tribunal but are inadmissible in stage 1. We are in the "finding of fact" stage now (stage 1).

Dr Webberley's counsel, IS, notes that the GMC has had years to respond to aspects of the defence's evidence but has declined to do so. IS states that Dr Webberley has not been a director of GenderGP since 2019.

IS submits testimony that demonstrates Webberley's competence to treat trans patients. IS points out the value of personal testimony as evidence of professional competence.

Counsel from both sides are putting to the Chair their arguments for and against the evidence supplied by patients and organisations being considered during stage 1.

IS states that these opinions and personal experiences are important as they demonstrate a wider picture of Dr Webberley's involvement in the area of trans healthcare.

SJ says that all material should be fully analysed before it's presented to the panel as he says many excerpts may not be relevant.

IS says that it would be unfair to Dr Webberley to be denied the inclusion of evidence that supports her case.

The Chair states that the panel have to decide if it's fair that the letters and reports are included as evidence. Fair to Dr W and fair to the public - who GMC represents.

The panel are going to retire now to decide if the material can be included now, later, or not at all. They will decide by 10.30am tomorrow. That is the end for today. The hearing resumes at 10.30am tomorrow morning.

Day 2: (content warning for arguments for deliberate psychiatric abuse against trans people) Hello, welcome back to Day 2 of Dr Webberley's hearing. Proceedings are due to start at 10.30am. Dr Webberley's (Dr W) counsel is Mr Ian Stern, QC (IS) and the GMC counsel is Mr Simon Jackson, QC (SJ).

The Tribunal Panel consists of a legally qualified Chair, a medical professional, and a lay member. We are expecting the panel to make an announcement on the contested evidence submitted by the defense yesterday, as to if it is admissable or not.

We've been informed that the proceedings will not begin until 11.30. We've not been told why. See you back here at 11.30.

The hearing has started and the Chair is announcing which evidence is not admissible. The panel states that an email will be sent with the draft determination, with reasons included.

Counsel for GMC, SJ says they would like to make a brief application, but first wish to verify a particular document. Chair suggests a break to read through the reasonings. Agreed to resume at 12.10.

Counsel for the GMC, SJ acknowledges that the application should have been made at an earlier date. Says he accepts responsibility and that they are trying to tidy up the allegations.

SJ requests beginning with Patient A. He says that following the initial consultation, Dr W failed to provide good clinical care and did not obtain an adequate medical history.

SJ says that the proposal is to insert the word "adequately" as the standard that is set is "to provide adequate care". SJ says that the word adequate just means what is expected of every doctor.

SJ is reading through the allegations and discussing the 2015 Good Medical Practice guidelines on adequate assessment/diagnosis.

SJ says that the assertion is that Dr W did not explore diagnosis of ADHD. He says there was a failure to provide a full psychological assessment and did not explore co-morbidities.

Regarding Patient C, SJ says that Dr W "Did not arrange for Patient C to be examined". SJ says there is no expert evidence that suggests that anyone has been advised to express an opinion on adequacy/inadequacy.

Dr W's counsel, IS refutes that patient C was not examined. "In the chronology, HW writes a letter describing face-to-face consultation...if you look at bundle 412-413, the date is clearly 11th August"

IS objects to the proposed changes and he questions why the charge that Dr W prescribed testosterone has not been removed, given that the patient was never prescribed testosterone.

IS says he objects to the amendments. He says there have been a number of versions of Heads of Charge that they've had to look at, that were added to following the expert review at end of March.

IS says that the notice of hearing was served on 21 June 2021 - "the lateness of any amendment is inherently unfair." He says that the amendment seeks to widen the scope rather than narrow it.Adds that no new evidence that has surfaced surrounding patient A.

IS asks the panel to look at what Dr Agnew says on p. 222. Dr Agnew: "There was a thorough, well-informed and appropriate exploration of gender dysphoria...the psychology input did not fully explore other diagnoses e.g. ADHD"

IS states there is an issue with the report of patient C and the allegation should be at Dr Pasterski.

IS states that in short, what this appears to do with adding new wording is to completely distort and extend the allegations.

IS says that regarding the physical and psychological assessment (1b2), according to GMC witness Dr Agnew, this was thorough and well-informed.

GMC counsel, SJ says that he disagrees. He says all cases brought by GMC are built on what is considered good medical practice. he says amending the change does no more than make sure that point is underlined.

SJ does not accept that this change widens the scope. He anticipates that Dr Webberley understands that good medical practice applies to all and submits that that is exactly how a Dr should approach any assessment.

SJ says the role of the prescribing doctor requires an approach that involves taking a full medical history, and requires the patient to be examined physically and psychologically.

SJ claims that in relation to patient C, there wasn't an adequate report and that the duty of a prescriber is that this assessment has been carried out to an adequate standard and ensure that the report is thorough.

SJ underlines that this does not provide for (in relation to Patient C) adequate assessment. he says that there was no parallel psych assessment - only an independent assessment in relation to Patient C.

IS states allowing this last minute change would set bad precedent - that the GMC can always add last minute changes just because it's "good medical practice". He says that "Good medical practice" is not a solid basis for an application to amend.

In response to a question from the Chair about the allegation Dr W prescribed testosterone to patient C, GMC counsel SJ says he will need to go back and check with patient C - but SJ says whether testosterone was prescribed or not is irrelevant as the same checks should have been carried out.

A discussion is happening about the relevant rules governing the tribunal, whether to accept amendments or not.

Chair says one of the matters considered is whether the defendant could have discerned the nature of an allegation which could be amended, or whether it comes to them entirely fresh.

Chair has they hope to have response by 2.30pm and asks can SJ make his application this afternoon? SJ says they will as soon as they can. SJ says that Patient C was prescribed T in due course. Adjourned until 2.30pm.

[Tribunal reconvenves]

The tribunal have decided that in 1b, 3b and 5a they will allow the word "adequately" to be added. The said they will draft the reasoning later. Dr W will now plead to the allegations. (IS will reply on Dr W's behalf)

Dr W admits to 10a, 28a, 28b and 29. These relate to issues to do with Dr W's prior conviction and regarding membership of the RCGP. Dr W denies all the other allegations.

SJ is saying that usually by the time the GMC gets to this point, they usually have clarity over bundles. But as recently as lunchtime, they don't know if medical records of Patients A, B and C have been uploaded & agreed.

Discussion is happening as to where medical records and witnesses sit in the defense bundle. The Chair says that the bundles need to be formalised.

IS says they are still waiting to be given the signed statement from Patient A's mother, but that they will have all they need.

SJ says the GMC are waiting to hear from the defense as to if the latest bundle can be uploaded. Some of the bundles have problematic numbers. Lots of discussion about bundles...

SJ says that Dr W has previously described herself as Senior Director of Gender GP and specialist practitioner in gender care. Dr W practised as an NHS GP since 2016. Qualified from Uni of Birmingham, Social Medicine 1992.

Dr W has been a member of WPATH since 2015 and has produced educational resources for Mermaids. MRCGP in 1996. SJ questions whether she can use MRCGP. There is no doubt she passed the exams, but GMC argues that she cannot be a member.

Dr W completed a course in psychosexual practice in 2002, gender variance course in 2015. Left her job as a GP in 2016 to help trans people and "set herself up" as an online practitioner with a specialist interest in gender dysphoria.

SJ says he will address the following issues: what is gender dysphoria, how has treatment evolved, how is the issue of treatment approached, how guidance and protocols been been created to cover this area.

SJ notes there is no formal training for Drs wishing to specialise in this area. SJ says he will discuss issues surrounding consent and capacity to consent and will look at Patient A, B & C in turn to see what experts say.

SJ says that GD is defined in DSM5 with a separate diagnosis for children. SJ says that GD must last at least 6 months and lists the criteria for a GD diagnosis. "It lasts at least 6 months" is important to the GMC case.

SJ says that although GD is considered a medical diagnosis it is important to stress that GD is a psychological condition that sometimes requires medical treatment. He says that when considering transition there are 3 separate stages: Stage 1: puberty blockers, stage 2: the administration of cross-sex hormones, and stage 3: gender reassignment surgery, which is only available via adult services to people aged over 18.

SJ asks the tribunal members to consider the guidance that was available in 2016 when they are considering the charges as since 2016 there has been further guidance.

SJ says that some of this will give us insight into how treatment has developed. But Dr W must be judged by 2016 standards. SJ says it's important to distinguish between treatment of children, adolescent, and adult patients.

SJ says that the timing of treatment with children needs to be carefully timed as they haven't gone through puberty yet. Certain criteria must be met for a child under 16 to be able to consent to treatment.

The patient must be able to acknowledge what changes they can expect and how they think treatment will help. They also need to understand the effect on their physical, mental, and emotional wellbeing and the uncertainties of how it may affect them in the future.

SJ states that the GMC observe that when children as young as 12 are allowed to consent to PBs that they may choose to go on at 16 to Cross Sex Hormones (CSH), which are not fully reversible.

SJ states that decisions about patients are balanced on the fulcrum of their current crisis and that key questions before prescribing are: has it been over 6 months and do they have the correct support?

SJ cites various international guidelines for best practice including a 2016 Amsterdam Clinic paper, a protocol on psychological pediatric endocrinology. From a 2006 paper "treatment outcome is expected to be more favourable when it begins after Tanner Stage 4/5, when they have had lifelong dysphoria, are psychologically stable and live in supported environment".

SJ says that "suppressing puberty should be seen as supporting treatment, but not *as* treatment" and that this was considered best practice at the time.

SJ says "Parent and child consent must be obtained." He adds that the child must be seen by a psychiatrist to dampen any unrealistically high expectations of future life and ensure they are informed of limitations for e.g on sex life.

Regarding the criteria for GD SJ says the patient is always seen by two members of the team. The decision regarding medication is always made by the whole team as per guidance from 2006. SJ says this guidance should be used to compare Dr W's approach.

The 2006 document is important for 3 reasons says SJ, because it details: - whether they should be treated - how - time taken to complete these stages

The paper says that "adolescents eligible for hormones are 16 years or over" says SJ.

SJ says 2008 NHS guidance on the care of gender variant people stated the role of the GP: "GPs may prescribe hormones or refer to specialists. GP may develop special interest & treat or make local referrals to multi-disciplinary teams".

SJ adds that he anticipates Dr W seeing that as endorsing her role.

SJ, reading from guidance says "It is desirable that patients are treated locally if possible." and that, "GPs with special interest can make the necessary referrals to multi-disciplinary care" (endocrinology, speech therapy etc).

The guidance also says that treatment for the gender condition should not be delayed unless strictly necessary for clinical reasons.

SJ says the question is not whether Dr W thinks she's a specialist, it's whether others consider her so.

SJ says that one of the issues - and we anticipate, the defense - regards bridging prescriptions. (e.g. for distressed, suicidal patients). SJ says that Dr W wrote bridging prescriptions for patients who were self medicating.

SJ says that patients who are already self medicating should be brought in to be helped and that a bridging prescription can help these people. He adds that hurrying them down the pathway can also have serious consequences.

Prescription can be used to bridge this distress while effective intervention takes place. SJ says young people presenting as the opposite gender are statistically more likely to be gay adults. SJ reads from the guidance: "Where the patient is a child, family & school support is essential...Many will desist & grow up gay/lesbian. But some will continue with serious distress." [Archivist's note: I'd love to know what he's citing, because it's not anything I recognise.]

SJ says that PB may be prescribed once puberty starts with the support of a pediatric endocrinologist. SJ discusses the importance of a multi-disciplinary approach to treatment - including pediatric endocrinologist & psychiatrist. NHS guidance at the time stated that: "A diagnosis of transexualism in a prepubertal patient cannot be made with confidence."

SJ says that experts must be able to diagnose co-morbid mental health problems and facilitate multiple appropriate interventions. Properly informed consent must be gained before HRT, potential side effects must be considered.

SJ says that the timing of medical treatment is important and it should follow rigid protocols including a pediatric endocrinologist and a counsellor. SJ stresses there needing to be a MDT.

WPATH 2012 guidance on the competency of MH professionals working with adolescents & children says minimum credentials: trained in developmental psychopathology, competent in treating mental health.

SJ says WPATH also stresses multi-disciplinary approach and says if this is not available, they must still engage a pediatric endocrinologist. Patient A was already engaged with the GIC, says SJ. GMC's contend that HW did not engage with the GIC.

SJ discusses the competencies & credentials required by various guidelines that were current in 2016 e.g. Master's degree, research in the field. he refers to NHS guidance:"GPs are encouraged to collaborate with gender identity clinics (GICs) on diagnosis and to develop treatment pathways".

SJ says that the treatment of trans people is primarily provided by GIDS. He says the GMC recognises that GOPs play an important role in supporting trans patients in providing non-specialised help and that GPs are encouraged to collaborate with GICS.

SJ asserts that Dr W set herself up as a consultant and that her practice was to prescribe without an endocrinologist and then pass the shared care to the patient's GP.

"When prescribing an unlicensed & experimental medicine, you must be confident in its efficacy & safety." says SJ. He says GPs must take responsibility for prescribing, ongoing care, monitoring, shared care agreements and maintain clear record keeping.

SJ says when not following common practice you would need to keep clear records as to why you are prescribing.

SJ says you must allow patients to make an informed decision by providing them with the full information and making it clear you are not prescribing this for its intended use.

SJ says you must also gain written consent. The Chair suggests a short adjournment, due back shortly.

SJ says that the GMC do not identify the medical qualifications of practitioners. Nor do we set the age at which patients can embark on treatment. He says the GMC's role is to provide regulatory framework.

SJ says It's important to understand whether Dr W was competent and experienced enough to prescribe to these patients. He says when practitioners take on responsibility for this care they must practice within the limits of their competence.

SJ asserts that Dr W didn't have the experience to prescribe to these patients. He says the tribunal is not about the principle of providing blockers or hormones. This is a recognised and widely-adopted treatment.

Central issue is whether Dr W, a general practitioner, was competent and experienced enough to meet the needs of these patients. Did Dr W obtain detailed psychiatric support for assessments?

The GMC contends that she should have liaised with GIDS and Tavi first and obtained records, before starting patients' regimen.

SJ says the GMC does not take issue with HW's publicised role in advocating better treatment for trans patients. Nor is this case about HW's status as a GP. The GMC recognises that some GPs have acquired additional special interest areas.

SJ says Dr W was not formally labelled as a GP with a special interest in sexual health or with trans patients. As recognised by WPATH "There must be a difference between a specialist and a 'self-described' specialist".

SJ says that Doctors outside of a hospital setting cannot specialise in transgender medicine. He says Doctors must not assume roles or elements of roles that they are not qualified to undertake.

SJ says "people achieve accreditation & experience in hospital settings. Not to say that GPs can't develop these competencies, but they must regularly take part in activities that extend these competencies" and that Dr W should have taken advice from the GICs.

SJ says that to specialise in transgender healthcare you must partake in work experience in a GIC or a registered private transgender clinic. The GMC alleges that Dr W did not undertake the necessary work to acquire competence. Dr W's experience of giving drugs to many trans patients is not sufficient to be a specialist states SJ, he says that there is no evidence of Dr W engaging in regular supervision or a MDT.

The GMC observe that Dr W's CV didn't show the required experience to work in this way with transgender patients. SJ says that not all children with gender variance will elect to transition and that there must be proper reflection on the unknowns with these treatments.

SJ stresses the importance of supervision and working with MDT - child & adolescent psychiatrist, psychologist, endocrinologist.

SJ says that while Dr W is an experienced GP who has taken an interest in GD youth, who has written and taken part in international conferences, he adds that forceful advocacy should not interfere with the prescription of blockers and hormones to young people.

SJ raises concerns that there has been a correlation between PB to CSH, he says that there remain many unknowns about treatments with such profound physical and mental implications. Can young people understand the difficulties?

That is the end of today's hearing, SJ will complete his evidence at 9.30am tomorrow. IS is requesting that each tribunal member have their own camera as IS and, SJ and Dr W cannot see their faces. the Chair said they will look into it. Day Three:

Day 3 is due to start at 9.30, follow us to stay abreast of Dr Webberley's hearing.

Today we're expecting to hear from Prof Gary Butler, consultant in Paediatric & Adolescent Endocrinology at University College London Hospitals. PB has “a specialist interest in Endocrinology and is the Medical Endocrine Lead for the National Gender Identity Development Service”

Chair invites SJ to continue with the GMC's opening. SJ and IS have discussed disclosure issues. There will be more material from each party later on. Updated allegation sheet has been handed out with the word ‘adequately’ added.

SJ is returning to his opening. The GMC observe that Dr W sought to make herself a MDT. He says these children were frustrated by the wait lists and approached Dr W to access treatment, and this lead to them potentially being dropped by the NHS.

SJ says that Dr W wrote that she offered, "a similar service to the NHS GIC, but in a more timely fashion and I have accumulated a large amount of experience in treating transgender people"

SJ says the standards were not on par with the NHS. The members of her MDT did not have the same qualifications as those that work at the GIC. If HW was trying to fill a perceived gap in the NHS, care shouldn’t be given at a lower standard.

Providing vulnerable patients with prescriptions online is fraught with difficulties and no shortcuts must be taken, states SJ. When prescribing gender-affirming hormones, the doctor must first consider coexisting mental health concerns.

SJ says there are dangers with not distinguishing other issues from gender dysphoria and there should be many checks before prescribing hormones to a child, including a full psychological evaluation and checks from a pediatric endocrinologist.

SJ says we must refer back to the established 6 months of gender dysphoria too as many patients experiencing gender dysphoria also experience other mental health problems. Care should only be provided to children in consultation with a pediatric endocrinologist.

GMC submit once a patient has been fully assessed with their full background medical history, only then can a diagnosis be considered.

The monitoring after of those patients prescribed treatment is just as important to ensure they are being prescribed the correct dose of CSH and that their mental health is okay.

There are obvious dangers in prescribing online to this cohort of patients, says SJ. It typically involves dealing with patients or relatives requesting or petitioning for prescription of gender-affirming hormone treatment.

With respect to patients that this tribunal will discuss we must consider whether they had the capacity to consent to the treatment, states SJ. In the case of Bell v Tavi they primarily considered the age of consent and SJ says some parallels can be drawn to this case.

The Gillick competence test states that a minor under 16 should be able to consent, provided that they understand the risks of the treatment and the implications they may have, says SJ.

SJ says that parental consent may override the child’s consent. The issue is whether Dr W adequately assessed the patient’s capacity to consent.

SJ says when applying the facts of this case we can decide if the child has "Gillick competence" to consent to the treatment being proposed by Dr W.

He adds that a patient suffering from gender dysphoria may be under so much distress that they cannot fully understand the risks and implications.

SJ discusses an example of Anorexia Nervosa, as an example that they are not ‘Gillick Competent. The GMC submits that the prescriber should also consider whether a patient has the capacity to consent, given their mental health.

SJ posits that a gender dysphoric patient who presents with suicidal ideation may not be able to give consent to treatment, he says it would require continued monitoring. GMC submits this didn’t happen with Dr W.

SJ references the Bell v Tavi case, the ability to consent is deemed as an individual one depending on the patient. Not all children can meet Gillick Competency, it will depend on their maturity.

The child does not need to understand every aspect of the treatment and causes but they must be able to understand the key aspects. In the case of PB and CSH fertility must be understood and explained fully by the doctor.

SJ says in 2016 there was clear guidance on what approach to adopt regarding adults experiencing gender dysphoria. He says it is "common sense" to apply this guidance to children.

The GMC recognise that there is a concern for patients self-medicating. This challenge may be met by a doctor prescribing bridging prescriptions.

When a doctor is faced with this decision there is guidance on how to approach this. When a patient is self-medicating a clinician can provide a temporary bridging prescription until more permanent care can be found.

SJ says that Patient A (Pt A) was known to be seeing the Tavistock & Dr W decided not to contact the Tavistock to discuss the patient's care. Providers that prescribe bridging hormones must work with a GIC to ensure the patients' care is taken over asap.

SJ says that some patients find it difficult to disclose their feelings of GD to their local GP. This can lead to a delay in accessing treatment and self-medicating. PB and CSH can be found easily on the internet.

Bridging prescriptions must only be supplied for a short period of time after the doctor is satisfied that the patient can consent fully to the treatment and that they understand the risks, says SJ.

SJ states the Dr W should have considered what point the child was at in being engaged with a GIC, as a GIC would be preferable. SJ says that dosages should be in line with the current guidance to obtain the optimum results in the safest way.

SJ states that providing sachets of testosterone as Dr W did, means that it cannot be delivered in the correct dose.

SJ states that if the patient requests treatment for GD that best practice is to refer them straight to their local GIC. Patients may face a long wait before seeing a gender specialist states SJ.

Transgender people face much higher rates of suicide and self-harm and GPs should refer them to a local mental health centre if they feel they're at risk.

SJ discusses when bridging prescriptions are appropriate, reiterating how important it is to support patients that are already self-medicating as they are at the most risk.

SJ states that a GP should only prescribe a bridging prescription if all the following criteria are met: a) the patient is already self-medicating b) the medication is to reduce the risk of self harm/suicide c) the doctor has sought advice from the GIC.

Council has requested a short break to read through the evidence that is due to be discussed shortly. Adjourned until 10.55.

[Court reconvenes]

SJ states that he finds it problematic that the GMC does suggest that bridging prescriptions should be issued by GPs, as it is beyond their competence.

In the case of gender dysphoria, SJ says that most GPs will have no experience with dealing with these patients. He says that the treatment for transgender patients is extremely specialised and should be provided by specialists, not GPs.

SJ summarises that his key concern is that the GP can prescribe safely. he claims that the GMC's suggestion that GPs should prescribe bridging prescription forces GPs to act out of their competence.

SJ says patients need access to specialist treatments, which is the responsibility of the NHS, so GPs should only consider bridging treatments in “exceptional circumstances.” This should be part of shared care with a GIC.

The GMC go on to say it is perfectly acceptable to prescribe unlicensed medicine and quite common. They recognise the difficult position that GPs are in considering the long wait lists that patients with GD face.

SJ says that the GMC don't want GPs to feel forced into prescribing outside of their competency.

SJ says that the GMC refute the idea that prescribing CSH (cross-sex-hormones) is an extremely specialised treatment as the same medication & guidance is used with patients with prostate cancer & endometriosis.

There were concerns about Dr W's treatment of Patient A, states SJ. Pt A was 12 at the time and had been under the care of the Tavistock for the last 2 years. Patient's A family contacted Dr W through her website MyWebDoctorUK.

There is no evidence of Dr W engaging in an MDT. A gender specialist must always work within a MDT says SJ, adding that there is no evidence of Dr W engaging in regular supervision.

To ensure Pt A had received the correct dosage of testosterone, a different method of application, other than a "quarter of a sachet" should have been used, states SJ.

SJ explains there is no evidence of a MDT approach to Pt A from Dr W and no physical examinations. SJ says testosterone being prescribed in sachets is unsuitable.

SJ states that as no MDT meeting had taken place, according to guidelines Pt A should not have started treatment. There was a failure to monitor the psychological well-being of the patient after prescribing testosterone in Pt A.

SJ discusses Patient B. Dr Walters was concerned that Pt B had been prescribed testosterone by Dr W after being referred to the local GIC. Pt B stated that he was taking half the "normal" dose. Dr Walters was concerned about Pt B's mental health but did not discuss this with him.

Dr Walters asked Dr Webberley to clarify the treatment plan of Pt B's medication. Dr Walters was not satisfied with the care that was described by Dr W and questioned which checks had been carried out, says SJ.

Pt B and his mother stated they were happy with the care they were receiving from Dr W and that they were hesitant to reengage with the GIC. After persuasion, they agreed to reengage with the adult service and Dr Walters subsequently prescribed a bridging prescription.

SJ states that Dr W's care fell seriously below the standard of adequate medical care by her failure to engage with the GIC or Dr Walters, failure to adequately monitor the patient after, and failing to keep proper notes.

Pt B, at 17 was prescribed testosterone by Dr W. Issues of consent are also raised regarding Pt B states SJ. SJ reiterates the need for an MDT and adequate care and monitoring.

SJ refers to statements from Dr Dean and Dr Agnew alleging that Dr W failed to explore an alternative diagnosis for Pt B.

Patient C, assigned female at birth, aged 11 was prescribed puberty blockers by Dr W. Dr Dean maintains that a copy of a signed informed consent sheet should have been obtained from the patient and their mother which wasn't done by Dr W.

In 2017 Dr Patel contacted the GMC about concerns regarding patient C, says SJ. Pt C received the closest treatment to what you could consider a MDT approach as he was seen by psychologist and gender identity specialist, Dr Pasterski

SJ states that the Royal College wrote to Dr W to ask her to not say she was a member, but that she continued to do so on her website and CV. Dr W had passed her RCGP exam for this, but failed to apply to membership. SJ states there is evidence she did know she was not a member.

SJ says that Dr W diagnosed Pt E with an STI without the appropriate checks and that she claimed to be a member of the Royal College when she was not. He adds that she was encouraged to join but didn't reply.

SJ asserts that in 2017 Dr W was suspended which meant that she was not allowed to continue prescribing prescription-only medication but she did anyway.

SJ says that Dr W omitted from her CV that she had links to Frost Pharmacy. She was sub-contacted to this pharmacy and so he says not declaring this was dishonest. Dr W said she stopped working with Frosts in January, but Dr Gale says they were engaged until May.

Dr W accepts that she didn’t inform Frost that she was no longer on the list. The GMC accepts that Dr W did not have a requirement to inform Frost, however SJ claims that Dr W should have kept them up-to-date.

SJ says that Dr Taylor became aware of concerns surrounding Dr W and recommended that Dr W status on the list should be reviewed asking should she be suspended pending the outcome of a hearing.

Dr Taylor produced a letter recommending an independent expert review about Dr W prescribing online.

The GMC were provided with a formal statement from Dr Jones stating he had been made aware of Dr W's online service being run without being registered. Dr W was convicted and fined £12,000.

SJ states we are not here to debate the politics surrounding transgender people and that we must ensure that the wider health and wellbeing of the wider population - it's not about giving patients exactly what they want.

Adjourned until 12.30, we will hear from Professor Butler this afternoon.

[Court resumes]

Professor Gary Butler (PGB), from UCLH has just been introduced as the GMC’s first witness.

The panel and other members of the tribunal are being introduced to Professor Gary Butler (PGB). PGB is struggling with his video chat function.

SJ is asking Prof Butler about his statements. They are addressing his 1st statement which deals with PGB's experience with Pt A. The 2nd statement deals with PGB's experience with Pt C.

SJ asks PGB if he’s had time to refresh his memory of his statements. He says he has had sufficient time and confirms that the statements are still accurate to his knowledge. The hearing is now being adjourned for lunch. We'll be back at 2:05.

[Court rejourns]

Dr Webberley’s representative, Mr Ian Stern, QC(IS) is cross-examining witness Prof. Gary Butler. IS states as they understand it there is one single provider - Tavistock - Butler agrees.

IS points to the NHS gender clinic services, questioning the protocols of the structure and how it works in practice. “UCLH do not have a gender dysphoria service.” IS asks is that correct? GB states that UCLH and the Tavistock are interlinked.

PGB says that whilst it is a subcontraction, “all of the consultations are done in parallel with The Tavistock. There’s always a member there.”

PGB states that the Tavistock is the only one of its kind in England and Wales. At the present time there are two endocrine clinics - London and Leeds but there are plans to expand.

"Why did Patient A travel to London to see you?” asks IS. Pt A was forced to travel from Leeds to London as they were the only centre in the country that could treat him, states PGB.

IS is questioning GB on his workload. PGB states it is accurate to say the number of patients being referred for gender-affirming care has increased globally. PGB adds that the service is constantly developing.

IS is talking about the UCLH website and trying to ascertain who else was working in gender care in 2016. IS wants the names of other practitioners from UCLH.

IS wants to know how PGB is registered with the GMC, what his specialism is in. PGB says he has dual registration, he is registered as a Paediatric Endocrinologist and that he’s done extra training for this.

PGB states he is involved with Great Ormond St and Tavistock - they are linked.

IS is saying that the increase in numbers must have has put great pressure on gender services. “There is a very large queue for endocrinologists,” says IS. PGB agrees but says it's important that they are diagnosed correctly.

PGB states that children are more likely to not be dysphoric than adolescents.

PGB tells IS that there is a long wait list for adults and children for gender-affirming treatment.

IS refers to the Care Quality Commission Report 2021. PGB says there are three CQC reports.

IS focuses on the Tavistock CQC report, he asks do UCLH and The Tavistock co-contract? PGB says they do.

IS refers to CQC doc as PGB has stated that Tavi and UCLH are interlinked. This document states that the service provided to the patients via the Tavistock is the only one of its kind in the country. PGB is now backtracking and stating that UCLH are not as closely linked.

A lot of backtracking from PGB. IS asks PGB, are you able to say that you have looked at any of the reports or material related to the Tavistock? PGB says he has.

IS continues to talk about the inspection of The Tavistock. PGB interrupts to say that he is not an employee of The Tavistock but he is an employer of UCLH. IS asks PGB does that mean he knows nothing about it then?

PGB disagrees and states that he works alongside The Tavistock but is employed by UCLH. IS asks PGB, “is this something you have knowledge of, or something you know nothing about?”

PGB states Patient A's referral that is included in the evidence as a good example of how full the referrals are when the endocrinologist receives a referral. PGB states that they take minutes of all of the referrals.

IS says what he is trying to understand is, was GB aware of Tavistock’s need for improvement? PGB states that there are questions raised as to how relevant this is on the CQC report as it was found that there is no duty of doctors to the patients on a waiting list.

PGB states it was an accident for the CQC to include this. IS states that the children waiting for help are at serious risk of self-harm.

PGB bats around the question as to whether he was surprised to hear that the people waiting for gender affirming treatment were struggling and he refuses to comment

IS says, "what I’m asking is, did the CQC assessments come as a shock.. or did you think The Tavistock was doing a good job?” GB goes onto to say that he goes through every patient carefully who is referred to him.

GB doesn’t see the relevance of the discussion and he doesn’t wish to continue this line of questioning.

IS states he asking these questions as PGB has written some of the NHS protocols. IS moves onto the review of the Tavistock services by Dr Hillary Cass. IS states that this review is taking place due to the issues found by the CQC but PGB states that he is involved in the review.

IS states the purpose of the Cass Review is to deal with the problems that have arisen from there being a single provider (Tavistock). PGB says he thinks that is one of the factors as to why they are doing the review.

PGB states that there should be local involvement in both GIDS and GIC because it is no longer containable within the specialised service.

PGB proposes more steps to reaching the gender clinics as a solution and states that every endocrinologist would be able to help a patient with gender dysphoria.

IS asks “even Paediatric Endocrinologists haven’t been sufficiently trained?” PGB says that they are well prepared to treat gender dysphoric children as they have a higher level of training.

IS says in 2017 PGB claimed to have over 600 patients with GD under his care. IS presents a document from 2018 stating that were are only 100 active follow-ups. PGB states he "doesn't know where that figure comes from" and stands by the 600 figure he gave the GMC.

IS is asking if PGB is aware of other clinics which are bigger than UCLH. PGB says he has a pretty good handle on them in Europe. “Is that the one you founded?” asks IS.

PGB states the treatments used in transgender are not unique, it is just that the application is different. All endocrinologists "would and should" be able to help a trans person go through the correct puberty for them but not all GPs would be able to.

PGB states the endocrine society produces relevant guidance from time to time and has encouraged WPATH to help with those guidelines. PGB states the guidelines were approved by many endocrinologists and organisations.

IS asked PGB would he say UCLH was the biggest clinic? PGB said yes "in the world" but then backtracked to "one of the biggest in the world" and settled on the largest in Europe.

IS draws attention to the NHS Standard Contract; GIDS- A Service Specification. IS asks, did GB have a hand in writing this? GB says he did along with lots of others.

PGB states he is very familiar with the document in question and confirms that it is the NHS standard contract for GIDS.

IS reads from it that GD can be more distressing during adolescents due to the development of secondary sex characteristics and increasing "social division between sexes" which can lead to increased risk of SH and trauma. PGB agrees it is a good description.

IS reads from the same document which states, "there has been some debate as to the minimum age for cross-sex hormones". There is some confusion between PGB and IS as to what 'gender assigned at birth 'means.

PGB states that they don't fully understand what makes someone trans but in the vast majority of cases the gender assigned at birth is correct. PGB states that it is more common that someone may be intersex than transgender.

IS asks PGB why he keeps referring to gender dysphoria as "very rare".

IS mentions that there have been differences in opinion about the age at which doctors feel it is appropriate to prescribe puberty blockers to children. He references the Bell v Tavi case.

PGB states that they regularly have audits but in the Bell v Tavi case there was a distinct lack of data available.

PGB states that no data has been published about those 18 and below taking Cross Sex Hormones (CSH). PGB says it is rare that an individual under 16 will have the capacity to consent to CSH.

IS asks if the problem is that there wasn't any triaging on individuals coming to GIDS. PGB says he used to triage the referrals to GIDS and the endocrine services. PGB states it is his knowledge that referrals are still triaged.

IS asks are some referrals to Tavistock are more urgent than others. PGB agrees there are. Puberty Blockers can now be considered for those under age 12 so long as they have reached tanner stage 2 says the NHS contract, PGB agrees.

The NHS contract states that so long as the criteria is met then PB can be prescribed by the patient's GP through a shared care agreement.

PB can be taken for a short period of time, PGB agrees they are not intended for long term use. CSH can then be introduced after the suppression of puberty.

Asked by IS about unlicensed medication, PGB states it is common practice to prescribe and use unlicensed medication.

IS asks is prescribing between Tavistock and the patient’s GP? PGB says it’s a shared care partnership with GP.

IS draws attention to referral management where it states that new patients should be seen within 18 weeks of being referred, which is a target that hasn't been met for many years.

IS says with the waiting time for Tavistock is it any wonder patients outsource care? PGB requests that they leave this line of questioning and requests the council make IS return to the case surrounding Pt A. Council says no.

IS reads from the NHS contract: "The service does not offer shared care with private clinicians but some patients may wish to access care from a private clinic or medication online." PGB states there aren't many patients that move outside of the NHS services.

IS questions PGB as to if there are figures as to how many people move from NHS services to private clinics? IS reads from the NHS contract which states that those obtaining gender-related medication outside of the NHS are cut off.

Adjournment for a short break, back at 16.05.

[Court rejoins]

Chair confirms that the documents re Bell v Tavi Patient A’s mother are now uploaded. Chair invites IS to continue with his cross-examination of PGB.

IS reads from evidence which states that as of 2019 the waiting time for GIDS was 22-26 months

GIDS didn’t provide age data as it hadn’t been collated. PGB says there was confusion and it was provided. IS states that there were 161 patients referred for PB including one as young as 10 by GIDS.

PGB protests the use of the word experimental when referring to PB. PGB stated that there were plans to review whether some young people could start CSH before age 16 but it never happened due to the legal implications.

PGB states that PB should be used short term, but that if they were prescribed as young as 10 they would have to wait 6 years until they could move to CSH.

Evidence suggests that most patients that receive puberty blockers go on to taking CSH states IS, PGB clarifies this statistic sits at over 80%.

IS is raising the lack of data from Tavi. IS says at time of the Bell v Tavi decision there was no material/ data available.

PGB reiterates that it's common to use unlicensed medicine. Discussion is happening about how much longer they will need with PGB.

The hearing is adjourning now. IS will resume his cross-examination at 9.30am tomorrow.