What is a bridging prescription?
A bridging prescription is a temporary prescription of hormone replacement therapy (HRT), typically oestrogen or testosterone, issued by a GP to a patient who is waiting for specialist treatment, usually at a gender dysphoria clinic (GDC, previously called the Gender Identity Clinic or GIC).
Why are bridging prescriptions necessary?
The average waiting time for a first appointment at a GDC in the UK is around 53 months (about 4 and a half years) as of May 2022, with some now having even longer waiting lists (1). No UK GDC meets the standard of care set out by the NHS constitution that patients have a legal right to wait no longer than 18 weeks for treatment by a specialist service. There are four new community-based clinics which may see patients faster, but these are currently only open to people who were already on a waiting list for another GDC.
Long waiting times exacerbate gender dysphoria and mental health problems, and increase risks of suicide and self-harm. Of nearly 800 trans people surveyed by Action for Trans Health in 2018, 63.5% reported that waiting for an appointment at a gender clinic had contributed to their suicidal ideation, and 32.7% reported that waiting for an appointment had contributed to them acting on suicidal ideation. Conversely, 84.4% of people who had previously experienced suicidal ideation reported that it occurred less frequently or stopped completely after they started HRT (2).
Many trans people also turn to self-medicating (buying and using unprescribed and unregulated hormone medication over the internet) because of the long wait for treatment at a GDC. This has the potential to cause serious harm due to potential contamination of unregulated medications, lack of oversight and monitoring in dosage and unknown contraindications (e.g. someone may have an allergy to a particular medication they are self-medicating with and not be aware of it).
Bridging prescriptions act as a ‘holding and harm reduction strategy’ (3), to mitigate the effects of waiting to receive care from a GDC and the resultant risks of suicide, self-harm and self-medication. They are issued on an interim basis, to be replaced by a prescription from a GDC.
What are the limits on bridging prescriptions?
Some sources, such as the General Medical Council, recommend that GPs only issue bridging prescriptions in cases where patients are self-medicating or considered ‘highly likely’ to self-medicate, where it is intended to mitigate a risk of self-harm or suicide, and where the GP in question has ‘sought the advice of an experienced gender specialist and prescribes the lowest acceptable dose in the circumstances.’ (4) A collection of resources about bridging prescriptions, including medical guidelines about them, can be found here.
Some NHS sources also suggest that a bridging prescription only cover an agreed upon period such as three months (5). Since patients will almost certainly be unable to access HRT at a GDC within this timeframe, such a timeframe effectively forces patients to come off hormones until they can start them again through a GDC. This is likely to have a profound impact on mental health, put them at risk of suicide and self-harm, and may make them more likely to turn to self-medication, even though bridging prescriptions are intended to mitigate these risks. Some GPs who do issue bridging prescriptions do not confine it to a pre-set timeframe.
How likely are GPs to issue bridging prescriptions?
Although in theory all GPs can issue bridging prescriptions, most are reluctant to do so. According to a 2020 study by GenderGP (6), 80.49% of GPs asked by patients for a bridging prescription refused to do so. In a similar study by Action for Trans Health in 2018 (7), 71% of GPs who refused to issue bridging prescriptions said that this was on the basis that they didn’t know enough about some aspect of medical transition.
Are there any resources I could share with my GP to support them to offer me a bridging prescription?
If your GP has not offered a bridging prescription for a trans person before, it might be useful to share some guidance with them. This will help them to feel more confident. NHS Wales’s Endocrine Management of Gender Dysphoria in Adults Prescribing Guidance for Non-specialist Practitioners offers comprehensive guidance in this area.
What can I do if my GP won’t give me a bridging prescription?
Bridging prescriptions are issued at the discretion of the individual GP, and they are not obligated to do so.
On the NHS, you have the right to ask for a new GP if you wish to without having to give a reason for your request (8). If your GP refuses to issue a bridging prescription, you can switch to a new GP and try again. You may wish to do some research about different GPs to see if there are any who you think may be willing to help you. Action for Trans Health have compiled a list of GPs with whom trans patients report positive experiences, although this is not a guarantee that any individual GP will issue a bridging prescription or be welcoming to all trans patients (9).
You can do this within the same practice at your old GP, or at a different practice. You do not need the consent of your GP to change GPs. When you have found another GP willing to accept you, you should contact them and ask if they will take you on. You do not need to tell them why you want to leave your old GP. However, if you are switching GPs specifically in order to try and obtain a bridging prescription, you may wish to ask your potential new GP if they would be open to doing this or if they have any experience treating trans patients before you switch over to them.
You can also make a complaint to your GP practice if your GP is not willing to issue a bridging prescription. However, it is worth keeping in mind that GP practices will often support the decision of a GP not to issue a bridging prescription, and you may be forced to take a complaint further. The potential for a lengthy and stressful complaint process has to be taken into account when deciding whether or not to complain. You may wish to seek help from a complaints advocate.
How do I make a complaint about a GP?
The first step in making a complaint about a GP is complaining to the practice. Typically, details of how to make a complaint are available on the practice website, often with an email address to send complaints to. Sending a complaint by email is often quicker, though using post may be seen as more official. If you send it by post, keep a copy of the complaint for your own records. You may wish to make some of the following points in your complaint:
- GPs have a responsibility to the physical and mental health of their patients. Arguably, a GP who refuses to issue a bridging prescription is risking your mental and physical health by failing to provide a safe source of medication, and failing to take action to mitigate serious risks of suicide and self-harm. If you are self medicating, you may want to raise the issue of insecure or risky sources, or unknown contraindications to the medication you are taking. If you’re not currently self medicating, you could suggest that not being prescribed hormones puts you at risk of mental health issues and self medication, and also at greater risk of transphobic violence due to being more visibly trans.
- According to the NHS constitution, all patients ‘have the right to access certain services commissioned by NHS bodies within maximum waiting times, or for the NHS to take all reasonable steps to offer a range of suitable alternative providers if this is not possible’. The maximum legal waiting time for a ‘specialist service’ such as a GDC is 18 weeks (10), a standard which no GIC currently comes close to meeting. (The average waiting time for a GIC is around 53 months as of May 2022.) It is the GDC’s responsibility to meet this standard, but the constitution makes it clear that when this standard is not being met, the NHS has a responsibility to ‘offer a range of suitable alternative providers’. Bridging prescriptions are the only form of such an ‘alternative provider’ generally offered by the NHS, so it is reasonable to say that GPs have a responsibility to either meet this requirement by issuing a bridging prescription, or offer an alternative source of treatment.
- The General Medical Council (GMC) has recently issued an updated version of its guidelines on decision making and consent (11). The new guidelines include the following point: ‘All patients have the right to be involved in decisions about their treatment and care and be supported to make informed decisions if they are able.’ This does not mean that any patient has the right to request a course of treatment and be given it. However, if a recognised treatment for a recognised medical need is available (e.g. a bridging prescription), and a patient understands the risks, benefits and side-effects of either having or not having that treatment, then the patient’s wishes should be a key deciding factor.
- GDC care has been seriously impacted by COVID-19. Many GDCs are not currently taking on new patients or issuing new prescriptions at all, and all have reduced services. Even where GDC appointments are available, you may be unable to safely travel to an appointment, since there are only a handful of GDCs in the country and many patients have lengthy journeys to reach them. In light of these extraordinary circumstances, it is reasonable to suggest that a GP has an even greater ethical impetus to intervene.
In your complaint you should make it clear what the problem is and how it affects you, and what you want to be done about it (prescription of hormones, and potentially a review of how trans patients are treated in the practice). You should make sure that you give them contact details, and discuss any ways in which you feel your GP, or other staff members at your GP practice, have been transphobic or otherwise discriminatory towards you.
If the complaint does not result in the desired outcome, you may wish to take it further. The next step after making a complaint about a GP is making a complaint to the NHS body in your region, either NHS England, Scotland, Wales or Northern Ireland. You can also make a complaint to the GP’s professional body, the Royal College of General Practitioners.
- The Tavistock and Portman NHS Foundation Trust: Gender Identity Clinic for Adults: https://gic.nhs.uk/appointments/waiting-times/
- Written submission on trans healthcare: http://data.parliament.uk/WrittenEvidence/CommitteeEvidence.svc/EvidenceDocument/Women%20and%20Equalities/Health%20and%20social%20care%20and%20LGBT%20communities/Written/104816.html
- Good practice guidelines for the assessment and treatment of adults with gender dysphoria: https://www.rcpsych.ac.uk/docs/default-source/improving-care/better-mh-policy/college-reports/cr181-good-practice-guidelines-for-the-assessment-and-treatment-of-adults-with-gender-dysphoria.pdf?sfvrsn=84743f94_4
- GMC guidance on trans healthcare: https://www.gmc-uk.org/ethical-guidance/ethical-hub/trans-healthcare
- Guidance for GPs, other clinicians and health professionals on the care of gender variant people, Department of Health, 2008: http://admin.fifedirect.org.uk/weborgs/nhs/uploadfiles/publications/c64_DH_085013.pdf
- Bridging Hormones, GenderGP, 2020: https://www.gendergp.com/bridging-hormones/
- Briefing on the impact of barriers to access gender confirmation healthcare for transgender patients on the NHS, Action for Trans Health London, 2019: http://data.parliament.uk/WrittenEvidence/CommitteeEvidence.svc/EvidenceDocument/Women%20and%20Equalities/Health%20and%20social%20care%20and%20LGBT%20communities/Written/104816.html
- How do I change my GP?, NHS: https://www.nhs.uk/common-health-questions/nhs-services-and-treatments/how-do-i-change-my-gp/
- Action for Trans Health – GP List: https://actionfortranshealth.org.uk/resources/for-trans-people/list-of-trans-friendly-gps/
- NHS Referral to Treatment rules: https://www.england.nhs.uk/rtt/
- General Medical Council guidance on decision making and consent: https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/decision-making-and-consent