What is Wrong with the Cass Report - and What is Right

 Dr Hillary Cass published her report into the way gender dysphoria services in the Uk have been mpoorly managed.  Much of what I read makes sense, but as appears typical to me, the passivity of NHS culture continues.

What do I mean?  The established culture I observe in mental health services is that there is little to no limit put on requests for services.  It is if the resource is, (or should be) limitless.  People make requests, and with very little screening, their requestings result in their names being placed on waiting lists.  The ides is that NHS services are good for you, so being on a waiting list is good.  Also there is the honourable idea that as citizens, all have a right to these services.  The waiting list is an inevitable and regrettable consequence.  There is also the unspoken belief that from a service perspective not having a long waiting list means that your service is vulnerable and possibly dispensable; next in line for cuts. 

Waiting lists occur when expenditure exceeds income (to use a financial metaphor).  Over the months, the debt grows steadily.  Eventually the overdraft limit is reached.  At this point the waiting list is at risk of dematerialising into a 'non-service'.  Even today I spoke to a mother who told me that her son was on a two year waiting list to be assessed for autism.  The letter she received states this as a matter of fact.  I have seen this methodology also used in the housing department when families are told that they are on a waiting list for a move to a council house in Cornwall.  What they have not been told is that this waiting list may be longer than the life they have left in them.  They are left with the belief that one day (not sure when) they will be moving away from this 'god forsaken place' to some wonderful existence elsewhere.  Consequently they never really put down roots or settle where they are.

In contrast I have worked for Social Services, where the answer is generally "NO" (oh, and by the way, what was the question?) This is an opposite philosophy when interventions are seen to have negative side effects, as well as positive ones.  Involvement is based on 'minimum necessary intervention', and very high demands on scarce resource is managed through this tough gatekeeping.  This system is also dishonest but in other ways.  Instead of being open about the scarcity of resources, the message is that the system is fine, it's just that you are not eligible. 

This is my view of the context of the Cass Report.

What was not said was that since the report 'Future in Mind' was published in 2015, there has been an emphasis on 'self referral' in Mental Health services.  This fits with the idea of freeing up barriers to accessing services, and emphasising people's rights to request NHS services.  Self referral was featured on the Tavistock Clinic Gender Identity Service (GIDS) website.  My understanding is that clinics were mainly based in London, but that there was another clinic in Leeds.  Future in mind also did away with the 'tiered' prioritisation model.  I guessed this was after hearing from articulate middle class parents distressed that they situations did not make them eligible to see a psychiatrist of psychologist.  The new idea was that all service could do a 'bit of this, and a bit of that.  It blurred the boundaries, and the flood gates were opened. 

The adult Gender Identity Service (GIS) based at the Tavistock has on its website an candid estimate of waiting time.  It says it has 15,086 people waiting, and that they see about 34 new people per month, with people waiting from Dec 2018 being next in the queue. They report receiving 406 referrals last month.  

This is the 'passivity' I am speaking of.  This message is 'it's not our fault, what can we do?  Give us more money and we can see more people.'

The Cass report rightly says that children referred to GIDS (the children's service) should have been directed to local mental health, and social services first, for more general care and assessments needed.  Often their gender dysphoria was a bit-part player in their overall distress, and local services saw the opportunity to 'off-load' work where they could, and especially if it was encouraged by the service itself.  Just like valium for depression, puberty blockers became the solution.  

Back at the ranch, local CAMHS services were playing the same game with long, unwieldy waiting list, and a their own culture of passivity, and disregard to the effects of long waiting times ("not my problem gov.")

In 1995, the New Labour government, in response to focus groups with patients and their representative, actually made significant changes to the status quo within the NHS.  At first they thought is was just money, but soon discovered that the money changed very little.  In child mental health, the Health Advisory Service published a report called  'Together We Stand' which addressed how the needs of the whole community could be mean wholistically.  They created the new mental health role called the  Primary Mental Health Team, which was designed to address the problem of waiting lists and inequality of access to services.  From the moment the Team came into existence it became subject to attacked from powerful professional groups within CAMHS itself.  The Primary Mental Health Team was designed to strengthen the interphase between universal services and the specialist CAMHS service.  This aim was  to ensure that only situations that merited specialist (and expensive) support was delt with by CAMHS.  Outsiders might assume that this would be what CAMHS might value, but no, CAMHS saw the limits placed by these boundaries as a threat to the status of the service in the wider community.  When the Primary Mental Health Team was allowed to work, with strong political backing, and with the strength provided by accountability to a multi-agency context, waiting time dropped to a maximum of 3 months (from 18 months to 2 years).  With the eyes of partner agencies on the work of the team, unacceptable practices became a taboo.  Indeed, the Primary Mental Health Team was able to do the same for other services, keeping us all focused on the only thing we shared- the children.  I am reminded that it is said that countries spend more money and time spying on their friends, rather than their enemies.  We kept each other in check.  As we worked together we could not wait say, 3 months for our partner agency to be getting its act together.  Generally all work was done within one month.

How will things change?  For me the only way is for citizens to take control again.  They must move away from 'poor NHS, covid heros, there is nothing you can do since covid came.'  The solutions are various, but one of them is to put the 'service' back into NHS, and see the patient's calling more of the shots.  And this is not through 'self-referral'.