The Levy review has been published

Today, the Levy review has published the findings from its review into adult trans healthcare provision. Its proposals, if implemented, would mean a significant shift in the provision of trans healthcare across England.

The review, conducted by Dr David Levy, was announced following the controversial Cass report into children’s gender services in summer last year. Dr Levy was tasked with leading a review into all of England’s nine NHS adult gender dysphoria clinics (GDCs).

The review examined the current operation of GDCs, and has made substantial recommendations for the improvement of adult trans healthcare provision. The review found significant issues with the current provision of services, including in waiting times and support, data on patient outcomes, productivity, and improving quality of services.

Concerningly, the review found that a majority of clinics had “exceptionally long waiting times” for NHS services, and that forecast wait time for newly referred patients had risen significantly – although the review concluded that the true size of the waiting list was unclear. Most GDCs projected wait times of 15 years or more if no improvements were made. The review also found that a significant proportion of referrals came from those who had aged out of youth services (150 of the average 830 referred each month).

The review noted that current wait lists were distressing for patients, pressured staff, and put patient safety at risk. NHS said that such waiting times were “unacceptable”, would exacerbate mental health problems, and increase pressure on other parts of the NHS. The review also noted that the waiting times led to patients self-sourcing hormones without proper clinical oversight and monitoring, often from “high-risk” sources, creating what it described as “patient safety risks”.

The review also found that waiting times led significant numbers of patients to seek private diagnosis and treatment. A lack of clarity and communication over waiting times exacerbated the distress caused by their length.

The review concluded that waiting times for services were unacceptable, requiring “immediate steps” to be taken by a “national network” to deliver improvements. It recommended that GDCs should be required to “actively engage” with a new National Quality Improvement Programme for Adult Gender Services, to quickly improve services. Today, NHS England announced that Dr Levy has been appointed as its independent chair, and that it will begin its work in January 2026. 

Perhaps the most significant recommendation of the review concerns hormone provision. Both patients and clinicians reported that GPs were often hesitant to prescribe hormones and monitor bloods as part of their shared care arrangement with the GDCs. The review notes an RCGP statement that “GPs are expert generalists; the provision of detailed advice about gender identity issues and associated treatments does not fall within the remit of a GP’s education and training”. The review concludes that GPs often feel they lack the appropriate expertise and confidence in prescribing and monitoring of hormone interventions. The review noted that this causes distress to patients, and puts pressure on GDCs and ICBs in managing relationships with GPs.

The review heard that patients typically stabilise on their hormones within one year of treatment, and that GDCs frequently manage this phase of care, with the appropriate expertise to do so. The review proposes a new model whereby GDCs will manage hormone prescription for a minimum of one year before discharging patients to local primary care services established by local or national commissioners. 

The review states that medical professionals must establish how GDCs and GPs can work more effectively together, within the limits of GP competence. The review recommends developing local hormone prescribing pilots, potentially using the GPs with Extended Roles model or other local models of care, and that there should be appropriate support from primary care providers for blood monitoring and hormone interventions, with the need for GDCs provide access and to work more closely with GPs for a more joined-up approach.

The review’s recommendations are extensive, but also included the following:

• A single, national waiting list for access to GDC services, with the expectation of consistent care. Patients would be informed how they could contact the holder of the national waiting list for information on patient-specific waiting times.
• The development of a standardised national support programme enabling patients to access appropriate local services while awaiting their first appointment. This information would be clearly given to patients and GPs upon referral.
• Reduce administrative burden by streamlining referral processes, and bringing an end to self-referral, which the review found placed significant additional demands on resources in trying to obtain all the relevant information from patients. This would be partnered with support for those struggling to obtain a referral.
• A separation of surgical care, which the review found caused a considerable number of unnecessary additional GDC appointments. This would allow patients awaiting surgery to be discharged back to GP care from GDCs at an earlier stage, with surgical units taking on relevant responsibilities.
• Specific provision for detransitioners, providing them with appropriate treatment and support.
• That first appointments should be conducted by senior clinicians, such as clinical psychologists or psychiatrists.
• The development, alongside NHS England, of an individual service-improvement action plan for each clinic.
• The provision of equitable access to gamete storage.
• Establishing a national minimum dataset so medium and long-term patient outcomes can be understood following treatment by the adult GDC and developing a national research strategy for adult gender dysphoria services.

NHS England has responded to the review, stating it has already taken several steps towards implementation. It says that its immediate priorities include bringing an end to self-referrals, ensuring earlier discharge from adult gender services, and working with professional bodies to establish a new professional role of GP with an Extended Role in Gender Medicine.

Good Law Project’s trans rights lead, Jess O’Thomson, cautiously welcomed  a number of the recommendations, while noting that there are still issues of concern.

“The review identifies the major barriers to accessing trans healthcare,” O’Thomson said, “and the serious impact this is having on patients. Urgent action is needed, and many of the recommendations – if properly resourced – would significantly improve provision. It is concerning that NHS England, in its response, does not commit to an increase in resources to enable these recommendations. 

“Some of the recommendations may also be problematic – requiring, for example, that first appointments are conducted by senior clinicians may impose additional barriers to accessing care. And it is vital that GPs do not use this as an excuse to withdraw longstanding healthcare arrangements for existing patients.

“The obvious solution,” O’Thomson continued, “is to adopt an informed consent model of trans healthcare, provided at primary level, rather than relying on gatekeepers.”