Brexit won't help to resolve key social issues faced by working class communities. So is it any wonder why I'm wholeheartedly backing a People's Vote?

Hey folks - I'm back!

It's that time of year again when many of us have been busily settling back into our work routines, figuring out how we're going to improve productivity, coupled with the odd “let's try not to break but ends up getting broken at some point or another New Year's Resolution” thought or two. This year seems more important than ever due to the impending date of our departure from the EU, ever etched in the minds of political folks as the 29^th March although this does now seem subject to change. Things have been heating up at Parliament, with MPs declaring support for the various positions that the UK should proceed in. My own preference is that the electorate be given an opportunity to make the final decision as to whether we accept whatever Brexit deal finally emerges out of Parliamentary discussions (although I have no idea what that deal could actually look like....it's probably not going to be Chequers Improved that's for sure) or reject the deal and decide to Remain in the EU and look to reform its structures (the option for a No Deal Brexit on World Trade Organisation terms needs to be on the table in the interests of fairness of course). The People's Vote campaign has been gradually gaining steam and attracting interest in Leave voting areas, including Lincoln, Mansfield and Sunderland and it's been pleasing to see the photographs of Brexitometers appearing on a weekly basis on Twitter and the accompanying comments about conversations campaigners have had, particularly with voters who declare they are Remainer Now. I'd encourage anyone interested in finding more about some of the personal stories of Remainer Now voters in Lincolnshire to follow the Lincoln for a People's Vote Twitter handle (@LincolnVote) as well as hashtag #LincolnRemainerNow.

What's clear from reading social media messages over the past month is that the People's Vote campaign face a huge challenge of getting working class people in leave-leaning surburban and rural areas proactively engaged in campaigning and buying into the reasons why a People's Vote is an important step in helping politicians to find an effective way forward out of the political stalemate they have found themselves in. Very few of my neighbours living in Birchwood, Lincoln have mentioned Brexit in public and those that have, tend to do so with a mutter of angst, disgust or frustration, depending on how invested they find themselves in the process. Even the Brexiteers of Birchwood, once emboldened by the promises of “taking back control” of Britain's sovereignty and seeing “real” constitutional change are more muted and contemplative. I'm reminded of one articulate gentleman who had told me back in early 2017 that I had nothing to fear from Brexit because leaving the EU would lead to Tory MPs realising they needed to end the austerity measures they had placed on local authorities, has now retreated to a position that only by getting the Tories out will mean Brexit can be fashioned in a socialist way and lead to an end to austerity. It's a subtle shift but it highlights where the real concerns are concentrated. The issues that the working class are facing are not actually due to mismanagement and harsh treatment by the EU towards us, its mismanagement and harsh policies imposed by the Government of the day. Well shit's got real y'all and there is little that seems certain politically.

When I talk to neighbours who voted Leave and Remain and neighbours who didn't vote in the 2016 EU referendum or couldn't vote in the referendum about what changes they want to see happen to improve the quality of their lives, similar comments emerge time and time again. They talk about wages and earning enough to keep a roof over their heads, homes heated and food on the table. If you're on a zero hours contract or only manage to secure less than 16 hours a week at minimum wage, you feel more on edge and uncertain about the future. The Universal Credit reforms introduced thus far have been botched and the effects on people struggling are well documented. I remember reading a Lincolnshire Reporter article in October which reports findings from a survey conducted with Lincolnshire residents dealing with Universal Credit: “Of those who had moved over to the welfare system, 46% of people said they had received help from a food bank. Some 29% had sought assistance from Citizens Advice” (https://lincolnshirereporter.co.uk/2018/10/universal-credit-leaves-many-hungry-in-lincolnshire/). A trainee midwife said that she was being “penalised” for studying and that had left her going into rent arrears. At a time when there are midwifery and nursing vacancies across the NHS (41,000) and more than 7,000 nurses and midwives from the European Economic Area (EEA) have already left the UK since June 2016 (https://www.ft.com/content/8f2d6e22-e7f9-11e8-8a85-04b8afea6ea3) this is just simply not acceptable and it's one reason why I think training bursaries for nurses and midwives need to be made available, so that trainees are not forced to endure financial hardship whilst studying and training for long hours.

Tory Austerity measures are making life harder for working class families and families who have fallen on hard times, whether that be due to being made redundant or a family member not being able to work because of the severity of illness or having to stay at home to care for a sick or disabled relative. Child poverty is becoming ever increasingly visible. I saw a BBC Breakfast interview with Siobhan Collingwood, a Headteacher from Morecambe who stated that 1 in 10 of her school's pupils came from families that had been forced to access a foodbank (https://www.bbc.co.uk/news/uk-england-lancashire-46827360). Ms Collingwood isn't alone. Teachers from across England have reported that students in their class are coming into school hungry and worried about the mental and physical health of themselves and their family members. Just last month The Guardian reported findings from the National Education Union which found teachers reported “that a lack of food, poor housing and unsuitable clothes are overwhelming pupils and cash-strapped schools”, with 2 in 3 teachers saying that more families of students attending their school were now unable to afford adequate winter clothing compared with just 3 years ago (https://www.theguardian.com/society/2018/dec/17/many-pupils-in-england-hungry-and-badly-clothed-say-teachers?CMP=Share_iOSApp_Other). Child poverty statistics paint a picture of a Britain that is far from being considered fair and equal. The Child Action Poverty Group has compiled a list of statistics (http://www.cpag.org.uk/content/child-poverty-facts-and-figures) which include the following:

• 9 children in a classroom of 30 will be living in poverty
• Children in large families are at a far greater risk of poverty – 42 per cent of children living in families with 3 or more children live in poverty
• By GCSE, there is a 28 per cent gap between children receiving free school meals and their wealthier peers in terms of the number achieving at least 5 A*-C GCSE grades.

Numerous reports have demonstrated how growing up in poverty can affect a child's chances academically and vocationally. This is particularly the case in the North of England. The 2018 Children's Commissioner report” Growing Up North” found that the most disadvantaged students in England are two years behind non-disadvantaged pupils by the age of 16 and less than a quarter of Northerners possess a Level 4 qualification (https://www.northumberlandgazette.co.uk/news/education/opinion-schools-and-colleges-need-more-investment-1-9533033). Educational inequality has soared on this Government's watch, with 3 out of 10 maintained secondary schools now reporting a financial budget deficit of nearly £500,000 (https://www.theguardian.com/society/2018/dec/17/many-pupils-in-england-hungry-and-badly-clothed-say-teachers?CMP=Share_iOSApp_Other). Recent research conducted by Lucy Powell, MP for Manchester Central found that independent schools are putting their students through IGCSE's for their EBacc subjects which are found to be less academically rigorous than the new GCSEs introduced by the Conservatives and which students in state schools have to take because access to IGCSEs is being phased out in those schools: in fact 91% of all entries for the EBacc core subjects were in independent schools this year (https://www.theguardian.com/education/2018/dec/30/labour-demands-inquiry-into-private-schools-evading-gcse-reform). Labour have quite rightly demanded an inquiry into this and hopefully it may lead to decisive action. Every child has the right to access a comprehensive, challenging academic education regardless of their socio-economic status.

Tackling educational inequality and child poverty should be two of the most important things on any Government agenda, yet instead this one seems utterly obsessed on getting Britain out of the EU and trying to convince folks in Birchwood and many other working class neighbourhoods across the UK that it's the most pressing policy agenda item and that social change will not happen without it. Far Right commentators tell us that social inequality is made worse by “the influx” of migrants that come to live and work in the UK. Perhaps one of the most disturbing things that happened during the Christmas and New Year break was the step up in coverage on illegal migration, with the Government deciding in their infinite wisdom to deem the efforts of a few dozen people coming to the UK illegally via the English Channel (and Mablethorpe) a “major incident”. What absolute claptrap. Ask the folks in Birchwood what they may deem to be a “major incident” or a “national crisis” and you would, I guarantee you, very rarely hear “illegal immigration into the UK” given as an answer. There were 201 confirmed migrant Channel rescues since November 2018 on the British side (https://www.telegraph.co.uk/news/2019/01/05/ignoring-difference-legal-illegal-immigration-penalises-migrants/). 201 compared with the situation in Southern Europe in 2015 when more than 10,000 people landed in 1 day in Greece (https://www.theguardian.com/uk-news/2018/dec/30/uk-migrant-crisis-bears-no-comparison-to-eus-2015-influx). Not exactly a national crisis. I get the importance of distinguishing between legal and illegal immigration for right-wing voters but for me, the UK has to take a compassionate and measured approach by ensuring that people who do attempt the English Channel or North Sea crossings are protected from danger and instead direct more anger towards the people smuggling gangs who are perpetuating those dangerous situations. Nobody can blame people who have experienced economic hardship for many years for wanting to search for a job in a country with better prospects.

Let's talk a little bit more about the Brexiteer argument that migrants are harming the employment prospects and wages of working class people. Contrary to what certain commentators may report, I've only spoken to 3 people in the last year who have expressed a clear concern about immigration along these lines. Most of my neighbours are concerned about keeping their own jobs or actually trying to secure a sustainable job, rather than spending time blaming EU and non EU citizens for the circumstances they have found themselves in. Numerous studies that have been conducted have concluded that immigration has little or no impact on average employment or unemployment of existing workers and where an impact was detected, although a 2018 study by the Migrant Advisory Committee found that “immigration from EU countries during the 34-year period from 1983 to 2017 had reduced the employment rate of the UK-born working age population by around 2 percentage points and increased unemployment by 0.6 percentage points” (https://migrationobservatory.ox.ac.uk/resources/briefings/the-labour-market-effects-of-immigration/). I believe that the emphasis needs to move away from painting a picture of migrants being in constant competition with British nationals to ensuring that all people have access to the education and training they need to develop skills to access the jobs market and to ensure that employers provide true equality of opportunity for all job applicants. I know that from bitter previous experience, being non-binary trans and having moderate dyspraxia. Figures from November 2018 state that 393,000 people who have disabilities were unemployed and the rate between July and September was 9.3%. People with disabilities have an employment rate that is 30.1 percentage points lower than that of people without disabilities (https://researchbriefings.parliament.uk/ResearchBriefing/Summary/CBP-7540). It's interesting that Brexiteers like Jacob Rees-Mogg seem to be perfectly prepared to align themselves who shout slogans like “British Jobs for British People” but never bothers to question why we have such a large employment gap between disabled and non-disabled people, a gap which I believe will not be closed significantly by stricter immigration rules.

I also recommend people share this article written by Aditya Chakrabortty, retelling the employment experiences of Robert, a Romanian who came to the UK to help others but ended up in insecure low-paid work and his experience at Nestlé’s Fawdon plant as an agency worker- an experience which many, British national, EU national or non-EU national would recognise (https://www.theguardian.com/commentisfree/2018/dec/12/myths-migration-stereotypes-insecure-low-paid-work). The far-right are primarily responsible for the perpetuation of stereotypes and fearmongering towards the small number of migrants who try to reach the UK illegally and I feel we need to fight against such fearmongering in a timely and robust manner. Centering the voices of migrants by encouraging and empowering them to craft platforms to speak out such as through blogging or podcasting is one way of doing this.

When I think of “major incidents” and “national crises” I think about what's happening to families and individuals who are being made homeless. The rise in homelessness rates is a national scandal and something the Government should be thoroughly ashamed about allowing the crisis to arise. According to the homelessness charity Crisis, 24,000 people will have slept rough this Christmas, this after an estimated 169% rise in levels of rough sleeping since 2010 (https://www.theguardian.com/society/2018/dec/20/homeless-deaths-rise-by-a-quarter-in-five-years-official-figures-show). I read a great letter from The Guardian online from Juha Kaakinen, CEO of Y-Foundation, a key organisation which helped devise the Housing First principle in Finland and help young people at risk of becoming homeless finding an affordable place to live. Juha argues that the supply of social housing in the UK has been sufficient and the Government needs to commit to rectifying this now the Homelessness Reduction Act has passed, using the plan created by Crisis. I read the plan last year which I thoroughly recommend: read it in full here: https://www.crisis.org.uk/ending-homelessness/the-plan-to-end-homelessness-full-version/executive-summary/. It includes limiting time spent by individuals and families in temporary accommodation and building 100,500 new social homes a year for the next 15 years to meet the needs of homeless people as well as funding for local authorities to provide a mandatory set of activities to help prevent homelessness, including family mediation and supporting people to keep their tenancies (https://www.crisis.org.uk/ending-homelessness/the-plan-to-end-homelessness-full-version/executive-summary/). Professor Mike Stein, from the University of York (my alma mater) also highlights the fact that there has been 25% increase in deaths of homeless people since 2015, - up to an estimated 600, partly as a result of lack of funding for preventative measures provided by public services (https://www.theguardian.com/society/2018/dec/20/homeless-deaths-rise-by-a-quarter-in-five-years-official-figures-show). Many of my neighbours, whether they voted to Remain or Leave, are well aware that life is increasingly tough for people in Lincolnshire who find themselves homeless, especially those sleeping rough on our streets or having to navigate the challenges faced as a result of living in temporary accommodation. I believe leaving the EU will not help one jot to alleviate levels of hardship homeless people face. Do not think that money saved from “paying for membership” will trickle down and lead to the building of more homes for the homeless, more services to help improve the mental and physical health of homeless people or the creation of additional jobs. Besides the Conservative Government could have chosen to relieve the burden of austerity measures on our local councils and allowed them to invest in more services. Instead we have to accept for the moment the drips and drabs funding and praise local councils who are trying to do their best under financial strain. One bit of recent good news is that a homelessness hub will open in Lincoln due to funding allocated under the £100m Rough Sleeping Strategy (https://www.bbc.co.uk/news/uk-england-46603795) but much more needs to be done long-term to ensure people do not end up falling through cracks in the system and end up back rough sleeping on the streets. That includes access to skills training, secure long-term council housing tenancies and mental health and emotional wellbeing support.

I couldn't do this blogpost without mentioning the concerns people in my area have about the pressures faced by our local NHS trusts, namely United Lincolnshire Hospitals Trust (ULHT), Lincolnshire Community Health Services (LCHS) Trust and Lincolnshire Partnership Foundation Trust (LPFT). I hear far more from my neighbours about waiting times for GP appointments and what they deem to be “unfair” hospital parking charges than I do about whether PM May's deal will lead to us struggling to secure a free trade deal with the US or how the coastline border will be secured. Research conducted by the Nuffield Trust found that people living in the top 10% most deprived areas of England find it harder to secure an appointment with their local GP because “there are markedly fewer GPs per head in poorer areas of England than in richer areas.....There was an average of 1,869 patients on GP lists for each doctor in the most affluent clinical commissioning groups (CCGs), compared with 2,125 in the most deprived” (https://www.ft.com/content/628b25ca-06d1-11e9-9fe8-acdb36967cfc). Emergency admissions are also nearly 30% higher in the 20% most deprived CCGs, compared with the 20% least deprived CCGs (https://www.ft.com/content/628b25ca-06d1-11e9-9fe8-acdb36967cfc). This is partly due to lack of awareness of self-care and prevention strategies for health issues such as smoking and obesity and yet this Government in their infinite wisdom is perfectly happy with presiding over cuts to the Public Health budget by £85m, which “will affect community and prevention services also including ‘stop smoking’ clinics, schemes to tackle obesity, and drug and alcohol misuse services for children and young people.” (https://www.huffingtonpost.co.uk/entry/government-sneaks-out-ps85m-cut-to-public-health-on-last-day-before-parliamentary-recess_uk_5c1bc9bee4b0407e90785176). Then we need to talk about the current state of our mental health services. A survey of GPs which was commissioned by the youth mental health charity stem4 and undertaken by MedeConnect Healthcare Insight found that 99% of GPs asked said that they feared that patients under the age of 18 would come to some form of harm if they faced lengthy delays in seeing a mental health specialist, with 27% stating that they greatly feared this (https://www.theguardian.com/society/2018/dec/30/inadequate-nhs-services-put-under-18s-with-mental-health-issues-at-risk). 90% of GPs surveyed also stated that existing health and social care services for under 18s is inadequate, with 37% saying they were extremely inadequate (https://www.theguardian.com/society/2018/dec/30/inadequate-nhs-services-put-under-18s-with-mental-health-issues-at-risk). This is concerning given numerous studies that have indicated a rise in levels of mental health problems among children and young people. The majority of GPs in this survey reported that they had seen a rise in the numbers of 11-18 year olds diagnosed with anxiety disorders (86%) and yet they say it is “impossible or very difficult for young people to get help with anxiety” (https://www.theguardian.com/society/2018/dec/30/inadequate-nhs-services-put-under-18s-with-mental-health-issues-at-risk). I wish Parliament was focussing their attentions much more on finding solutions to addressing mental health service provision rather than expending most of their energies on pushing forward with Brexit and having to make provisions to stockpile medicines in the event we leave without any deal with the EU. I mean I'm sure nobody could have foreseen that a form of Brexit that hopefully will never happen has led to the need of the Department for Health to buy 5,000 fridges to store medicines. Not to mention increasing concerns regarding staffing levels in the NHS post-Brexit under the Tories because of the policies outlined in their Immigration white paper. Currently there are numerous hospital staff members who do not earn £30,000 a year: “the starting salary for nurses, midwives and paramedics is £23,000. Junior doctors start at £27,000 while healthcare assistants are at £17,000. Most scientific researchers also earn below the proposed threshold” (https://metro.co.uk/2018/12/19/brexit-migrant-salary-cap-devastating-nhs-schools-experts-warn-8266041/). This on top of the fact that our NHS is short of 107,743 staff overall makes me think how ridiculous it is for those middle and upper class Brexiteer campaigners to crow on about migrants taking jobs British people want to do. I'm all for rises in wage amounts but I very much doubt hospital trusts can afford to raise the salary of a healthcare assistant to £30,000 in one go.

In this blogpost so far I've touched on just a few of the key social issues that we will face as a country in 2019. There are many others I could have mentioned – animal welfare, plastic waste pollution, emergency service strains – ambulances and policing, access to legal aid etc. They are issues that many of us, whether we voted to Remain or Leave in the 2016 EU Referendum care about resolving and issues that will need significant funding and fresh idea generation if we are to address socio-economic inequality. Thus far Brexiteers on the far-right of politics have failed to supply an explanation as to why we must leave the EU in order to tackle systemic socio-economic inequality. Those on the left who define themselves as staunch Brexiteer socialists, aka Lexiteers have tended to put forward arguments that centre around the idea that the EU is somehow deliberately preventing politicians in the UK from putting in place policies that could reduce austerity and lead to greater investment in areas such as Lincolnshire. This is particularly the case when it comes to the question of renationalisation of national infrastructure- i.e. the EU would prevent Labour which favours renationalisation of the railways and the energy production network, from renationalising them, because its rules favour the private sector. The State Aid question has been debated by numerous commentators but I find George Peretz's explanation quite helpful. In particular it was interesting to note that “the UK gives much less state aid per head than most EU countries, under-using the scope that it has within the state aid rules to support (for example) industrial training and regional development.” (https://www.theguardian.com/commentisfree/2018/dec/27/four-reasons-jeremy-corbyn-wrong-eu-state-aid?CMP=Share_iOSApp_Other) Yet again another decision taken by the Conservatives not to invest appropriately through having an ambitious Industrial Strategy rather than the fault of the EU. The idea that the EU is some kind of “authoritarian state” and we somehow have to leave it because if we don't we can't then create a truly socially democratic UK sounds a bit far-fetched to me. The rules that have come about as a result of EU membership have, on the whole, been widely accepted without significant critique, other than from the usual quarters. I'm thinking for example, of the recent General Data Protection Regulation which has helped to give individuals more control over how their data is used and retained by organisations- e.g. the right to erasure which “allows individuals to request that personal data be deleted or removed in certain circumstances such as withdrawal of consent or when that data is no longer accurate” (https://blog.centrify.com/consumer-privacy-benefits-gdpr/). Being a member of the EU has meant the Government has had to adopt changes and improve rights and I for one think that's great. So when people complain about EU legislation and regulations being imposed on us, I remember the rules that have been adopted, such as GDPR and The Working Time Directive and how they have and are making a positive difference in our lives. So yeah....EU authoritarian state....what absolute poppycock!

What also gets my goat is how Lexiteers can talk about the EU system being unfair and anti-democratic when we see what our own Parlimentary system is like. How can they honestly say those things with a straight face when we are the ones who still have an unelected House of Lords with hereditary peers and Anglican Bishops being able to have a direct say in our decision making and we have a system which ends up concentrating most of the power in the hands of two parties? I certainly admit that the EU Parliament is far from perfect but maybe we need to consider working on democratising our own Parliamentary system before deciding to mock others for being anti-democratic. On the plus side, if Labour were to be elected in a General Election this year there could be steps taken on long-overdue constitutional reform, not least lowering the voting age to 16 and potentially introducing a referendum on Proportional Representation (I know, “Not Another One”). Such moves would do a lot more to work towards crafting a more modern democratic system than leaving the EU. Mind you, some Lexiteer socialists will just dismiss me as a “neoliberal” or a member of the “metropolitan elite” and consequently dismiss such concerns. It's amazing to think how people on low incomes can be so easily labelled as being members of “The Establishment” these days if they disagree with leaving with the EU and are prepared to do so publicly. Well let me tell you, resurrected eurosceptic Benniteism isn't going to win me or other working class liberal left Labour voters over (yes we do exist!!). 

Instead, I think the focus needs to be on outlining a positive, progressive vision for the UK that aims to address social issues. It's the biggest challenge that a campaign for Remain during a People's Vote referendum needs to overcome. People know that we don't want to Leave the EU but what are we going to offer to improve the lives of voters in Mansfield, Redcar, Lincoln and Preston so that those voters would be sufficiently satisfied to vote for that Remain vision. Commentators and MPs have begun to outline such visions. For example, Zoe Williams in her Guardian article states that “A positive vision for the future needs solid answers to urgent questions: climate change, austerity, the erosion of workplace rights, the rise of fascism. All of these feed into one another to create a sense of precariousness and threat, and all solutions involve cooperation across borders. The new remain movement must articulate a future in which opportunities and freedoms expand rather than retract, citizens’ rights ratchet upwards in a race to the top, revivified unions support one another internationally, a green new deal echoes across multiple governments, racism is answered robustly and migration celebrated, and the dreams of the EU’s founders – peace, reconciliation, solidarity, equality – are rediscovered.” (https://www.theguardian.com/commentisfree/2018/dec/23/labour-remain-jeremy-corbyn-brexit). Such a vision encapsulates much of what I believe and there is a lot of policies within the current Labour manifesto that could be adapted- I'm thinking introducing three year tenancies in private sector as standard, safeguarding homeless shelters, scrapping the draconian bedroom tax for starters. I want to see those policies enacted, but I fear it will be more difficult to enact them outside of the EU.

Brexit is neither necessary nor will benefit working class communities. The core systemic social issues that need addressing will not be addressed by a Conservative Government pushing through Brexit in any form, particularly a No Deal Brexit that could lead to further perpetuation of the Austerity Agenda. Once PM May's deal has been voted down in the House of Commons and the vote of no-confidence has failed, I hope more Labour MPs in particular will join the People's Vote campaign and push for the Final Say on any final deal PM May or other Tory leader manages to cobble together. If not, then I hope MPs realise that working class constituents will need their help more than ever as the country deals with any potential economic turbulence resulting from Brexit.

The UK Government's LGBT+ Action Plan....It's a start?

This week the UK Government released the findings of their National LGBT+ survey, conducted last year. There were 108,110 valid respondents from people living in the UK aged 16 and over. 61% of respondents were gay or lesbian and 26% were bisexual. 13% of respondents were trans, with 6.9% of respondents (7,800) being non-binary, 3.5% being trans women and 2.9% trans men. Interestingly, 2,970 responses were rejected because they were deemed "offensive, abusive, explicitly vulgar or otherwise unreliable"....I'm guessing some of those responses came from Trans-Exclusionary Radical Feminists (TERFs) spouting discourse against trans people so I'm glad there were robust checking procedures as part of the research collation and analysis. I'm going to be examining the report in depth and doing a number of blog posts over the month on the results of the National LGBT+ Survey but you can read the entire 304 page research report for yourself if you wish to here:https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/721704/LGBT-survey-research-report.pdf.

There are a number of statistics that have come out from the analysis of the LGBT+ survey that I feel need to be communicated widely:

• Trans respondents were much more likely to say that they had a disability (33%) than cisgender respondents (14%)
• Trans people had lower scores for life satisfaction in the UK: trans men scored on average 5.1/10, trans women and non-binary people scored on average 5.5/10 (the average for the UK population at large is 7.7/10)
• Only 37% of trans women, 34% of trans men and 38% of non-binary people said they felt comfortable being LGBT in the UK
• 72% of non-binary respondents had not disclosed their gender identity to their neighbours
• 68% of all respondents (who were lesbian, gay, bisexual, asexual or pansexual) said they had avoided holding hands with a same-sex partner in public
• 70% had avoided being open about their sexual orientation because they feared they would face a negative reaction
• 59% of trans women, 56% of trans men and 76% of non-binary people who responded to the survey have avoided expressing their gender identity openly but younger cisgender people were more likely to be open
• 24% of all respondents were not open in any way about their gender identity or sexual orientation with family members they lived with (excluding their partners)
• 40% of all respondents had experienced a negative incident in the 12 months prior to filling in the survey when the perpetrator was someone they did not live with on the basis of gender identity and/or sexual orientation or being perceived as LGBT
• 26% of all respondents had been subjected to verbal harassment in the last 12 months prior to filling in the survey
• 14% of respondents had their LGBT status disclosed to others without their express permission in the past 12 months prior to filling in the survey
• 6% of all respondents had been subjected to threats of physical or sexual harassment or violence in the 12 months prior to filling in the survey
• 2% of all respondents had experienced physical violence in the 12 months prior to filling in the survey
• 2% of respondents had experienced sexual violence in the 12 months prior to filling in the survey
• 11% of respondents had had private sexual images and/or videos shared without their explicit consent in the 12 months prior to filling in the survey
• 94% of respondents did not report the most serious incident they had been subjected to when the perpetrator or observers were people they lived with
• 45% of respondents who reported incidents to the police were unsatisfied with how reports were handled
• 5% of respondents had been offered conversion therapy and 2% had undergone such therapy
• 51% of conversion therapies were carried out by faith organisations and groups and 19% were carried out by a healthcare professional/provider
• 77% of overall respondents said that neither gender identity nor sexual orientation was discussed in their school lessons but this dropped to 54% amongst 16 and 17 year olds
• Only 9% of those respondents who had lessons on gender identity or sexual orientation said their lessons had prepared them for later life as an LGBT+ person
• 88% of the most serious incidents reported by respondents in education were perpetrated by a fellow pupil but 9% were perpetrated by a member of teaching staff
• Only 36% of respondents who were transitioning at school said their school was very or somewhat supportive of their needs
• 21% of respondents who stated they were trans who accessed healthcare services said their needs had been ignored: 18% said they had been subjected to "inappropriate curiosity" and 18% also disclosed that they had avoided treatment because of fear of discrimination
• 87% of respondents who had accessed sexual health services in the 12 months prior to filling in the survey said they had a positive experience
• 80% of trans respondents who accessed or tried to access gender identity clinics said it wasn't easy, with the waiting time being seen as the greatest barrier 
• Only 7% of non-binary people had accessed gender identity services with another 6% trying to access services.
• 23% of respondents had experienced a mixed or negative reaction whilst at work due to being LGBT or being perceived as being LGBT, with 9% being subjected to verbal harassment
• 57% of the most serious incidents reported by respondents as happening in the workplace have been perpetrated by a colleague (junior or at same level).

This short list of statistics will come as no surprise to those of us who have spent our lives trying to navigate challenges that originate as a result of ignorance, fear or blatant discrimination by those in positions of power and influence. My blog posts and those of many other LGBTQIA+ people are testament to that. The question is: how can the Government enact policies and legislation to improve the lives of people like me and the lives of those who may not yet have come out as LGBTQIA+?

The Government LGBT+ Action Plan, announced alongside the results of the National LGBT+ survey today aims to address the concerns of LGBT+ people expressed in the survey and by campaigners aiming to improve LGBT+ equality. There are 75 points to the plan and £4.5m announced to specifically support the enacting of the Action Plan which will be available till March 2020, with an LGBT+ Advisory Panel set up to help deliver it.You can read the full document here: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/721367/GEO-LGBT-Action-Plan.pdf.

One of the headline policy statements from this Action Plan is that conversion therapy will be banned, whether through passing new legislation or exploring non-legislation (i.e. regulatory) options. Conversion therapy is dangerous whereas affirmative therapy helps to improve the mental and physical health of LGBTQIA+ people who struggle initially with accepting their sexual orientation or gender identity. I hope conversion therapy of any kind on the basis of sexual orientation or gender identity will be banned, so that we can particularly protect vulnerable trans, gender-diverse and gender-questioning children and young people from being forced to accept gender identities to "fit in" with parental, religious or other expectations. I'd rather see it banned via the introduction of legislation but will wait to see what is recommended by the Government in the next few months.

I welcome and approve of the announcement of a national LGBT+ health adviser and hope I and many others will have an opportunity to meet them to discuss my concerns about the lack of awareness of trans and non-binary people's specific needs, so that we can improve standards of patient care and make our hospitals, GP surgeries, care homes and other spaces a more inclusive and welcoming place.

I'm happy to see the announcement on addressing body image pressures that LGBTQIA+ young people in particular face and hope there will be funding made available for specific body positivity campaigns at grassroots level so that young people themselves working within third-sector and public organisations can help challenge pervasive cultural body norms.

There is a need to help improve the lives of LGBTQIA+ people who have a learning disability so they have the confidence and freedom to engage in activism, in education and in loving relationships. Training for care professionals and carers is vital and that means updating advice and guidance documents in collaboration with charities and other third sector organisations who work on a day-to-day basis with people with learning disabilities.

The approach towards reporting and responses to reports of LGBT+ hate crime needs to be improved so that LGBT+ people have more confidence in the police and the overall system. I appreciate the announcement of a refreshed Hate Crime Action Plan and look forward to reading the recommendations regarding training of police officers and raising awareness of hate crime reporting routes in the local community. It's good to hear that "The Home Office and Ministry of Housing, Communities and Local Government will... fund a bespoke training package available to all police call handlers to help ensure victims are correctly identified and supported at this critical first point of contact" (p.17) and that the Crown Prosecution Service will work with their partners to improve reporting procedures for LGBTQIA+ victims of domestic abuse, rape, sexual assault and hate crime. However I'd like to see the Government adopt Labour's proposal for making LGBT+ hate crimes aggravated offences to deter perpetrators and send a clear signal that such crimes will not be tolerated.

I'm cautiously optimistic at the recommendations in the Action Plan to increase support for LGBTQIA+ survivors of domestic abuse. Police forces need to ensure that LGBTQIA+ people are aware of the support services they can access and that the review of domestic abuse services will highlight gaps in provision and provide recommendations to improve support packages. The non-legislative package of support which is being created to align with the Domestic Abuse Bill needs to fully consider the needs of LGBTQIA+ survivors. Increasing awareness of Sexual Assault Referral Centres for LGBTQIA+ survivors is also extremely important and I hope that any resulting marketing campaign will be created in full consultation with LGBTQIA+ organisations and the participation of survivors. 

LGBTQIA+ teachers, support staff and pupils all deserve to feel safe and secure whilst attending school or college. More school and college leaders should be encouraged to create or update their policy and procedures and ensure that all staff attend appropriate training which improves awareness of LGBTQIA+ issues but also provides practical, sustainable techniques and measures that can be used to improve LGBTQIA+ equality. Relationships and Sex Education, (when it is eventually introduced) must include LGBTQIA+ awareness and equality and guidance needs to be issued to schools and colleges which is fact-based, comprehensive and easy-to-understand. I'm also pleased to see a commitment from the Crown Prosecution Service to update their LGBT Hate Crime Schools Pack and will do so with the input of LGBTQIA+ young people and the Government's Equalities Office will work with the Equality and Human Rights Commission to produce comprehensive guidance to support trans, gender-diverse and gender-questioning children and young people.

It's good to see a commitment by the Government's Equalities Office to provide employers with free training materials to help them create a more inclusive working environment as well as creating an employers' working group to discuss key issues. I hope a range of organisations, large and small from across the UK can contribute to this working group and help with the creation of training materials.

I appreciate that non-binary people will have the opportunity to contribute towards a specific Call for Evidence so that ministers and decision makers alike can hopefully improve their awareness of issues that affect us but I hope they will continue to or begin consulting with experts who have extensive experience of working with non-binary people. The Gender Recognition Act needs radical reform to improve access to legal recognition for non-binary, agender and gender-fluid people and there needs to be appropriate and safe opportunities provided for non-binary, agender and gender-fluid people to contribute to the Gender Recognition Act (2004) consultation, without fear of being subjected to verbal abuse and harassment from opponents. I also welcome the attempts that will be made to make it easier to make changes to gender markers (which I hope will soon include non-binary ones) legally through a "Tell Us Once" type service. It could reduce the bureaucratic cost and ensure all documents are kept up-to-date as per current General Data Protection Regulation and Gender Recognition Act requirements.

Intersex people deserve to have their right to be protected from direct and indirect discrimination, victimisation and harassment enshrined within our legislative framework. The Equality Act (2010) should therefore be amended to include intersex as a protected characteristic. The National LGBT+ Survey had 1,980 responses from intersex people living in the UK and one important statistic that came out was that 16% respondents said their GP didn't know where to refer an intersex patient for further advice and guidance. It's important therefore that healthcare professionals receive appropriate training as part of their Continuing Professional Development (CPD) requirement so they have more awareness of intersex advice organisations and provide the right advice and guidance to support patients. Equally there needs to be a bill brought before Parliament to ban unnecessary cosmetic sex assignment surgery on intersex infants and young people and procedures brought in so that intersex people have the undeniable right of access to their medical records to find out what surgical interventions they had been subjected to.

I must say I am disappointed to see a firm commitment to bringing marriage equality to Northern Ireland, but given the current political situation with Brexit, and PM May's reliance on the votes of DUP minsters, I am not surprised. LGBT+ people in Northern Ireland deserve to enjoy the same rights as those living in London or Lincoln and I hope that the next Labour Government will push more fervently for reform if this current Tory Government fails to do so. That being said, the Government has now committed itself to putting on an international conference on LGBT+ issues so I hope that will provide an opportunity to address LGBT+ discrimination in Commonwealth countries (there are still 37 countries where homosexuality is still criminalised). There is also the idea of the UK bidding to co-chair the Equal Rights Commission in 2019 so we shall what happens with that in the next few months.

I'm also disappointed at the lack of detailed policy reform to support LGBTQIA+ asylum seekers who come to the UK to escape persecution on the basis of their sexual orientation or gender identity. We need to end the hostile approach (which has led to what has been dubbed the "Rainbow Rush scandal") and do this by bringing to an end the detention and deportation of LGBTQIA+ asylum seekers and speed up the application process for all asylum seekers so that they can all begin to rebuild their lives knowing they have a safe place in which to do so. It is good nonetheless to see a commitment to reviewing guidance for caseworkers and reviewing the training of professionals dealing with asylum claims across the board. Let's demonstrate our compassion and fight for and protect the rights of all LGBTQIA+ people living in the UK, whether they are British citizens or not.

There are policies to be commended in the LGBT+ Action Plan and if implemented in full, it will lead to improvements to the lives of LGBTQIA+ people across the UK, through the dissemination of knowledge, increased participation opportunities for engagement on policy and a systematic shift in the way key societal institutions view LGBTQIA+ equality. As Dawn Butler, Shadow Secretary of State for Women and Equalities highlighted in her response to the LGBT+ Action Plan, there is a need for sustainable funding so that policy actions and consultations can take place. It's a reasonable start, but no campaigners would deny there is still much to do.

Tory Austerity Lite's Still Failing Us: Autumn Budget 2017 Thoughts from 4 Voters in Lincoln:

As I've done several times before in this blog, I thought it'd be interesting to examine and
scrutinise the Autumn Budget 2017 policy measures with a group of 4 voters from Lincoln. 2 of them (Voters A and D) fall into the still much cited category of "JAMs" -the Just About Managing voters (who are described as barely affording to pay essential bills but still have enough  disposable income to afford a few treats in the year) whilst 2 of them (Voters B and C) can be described as more comfortably well off.

The voters have different political affiliations and voted differently on Brexit in June 2016.

1. Administrative Assistant at an Accountancy Practice. Labour voter who voted to Leave the EU.
2.  Owner of a logistics firm. Conservative voter who voted to Leave the EU.
3. Sales and Marketing Manager at a local firm. Labour voter who voted to Remain in the EU.
4. Charity Shop Worker. Lib Dem voter who voted to Remain in the EU.

Here's a few summary points from the discussion (for those who don't have time to read the whole table):

• Most of the voters were happy with announcements on Maths and Science teaching, the prospect of a 26-30 discounted railcard  and appreciated the freeze on Fuel Duty and Alcohol Duties (except for white ciders). 
• Most of the voters believe the abolishing of the Stamp Duty will help some first-time buyers but there needs to be more support for private renters.
• Voters A, C and D thought that there should be an increase in the Council Tax Premium levied on empty home owners in Lincoln.
• There was some concern shown as to whether some of the funding increases/ allocations announced would actually benefit Lincoln residents in the long-term especially housing funding. More detail needs to be offered by the City of Lincoln Council and Lincolnshire County Council on this as they begin to assess what the Budget will mean for Lincoln and Lincolnshire.
• Voters A and C thought that investments in R&D were too high and that some of the money should be diverted to help sustain frontline public services instead (Schools and Hospitals in particular).
• Voters noticed the absence of funding allocated to Social Care and Policing and attributed that to Brexit.
• Voters expressed dismay at the lower than expected increase in the National Living Wage for the over 25s but were fairly pleased with the planned increase in the Personal Allowance.
• Voters A, C and D were highly critical of the Universal Credit announcements and want to see the Government pause the roll-out until issues are addressed.
• Voters A, C and D are worried about potentially leaving the EU without a free trade deal.
• Voter intentions seem to remain unchanged although Voter C did state they were undecided at the moment because of how Labour are handling the Brexit negotiations.

Here's the results below:

Autumn Budget Proposal	Voter A:	Voter B:	Voter C:	Voter D:
£3bn to help the UK prepare for Brexit over the next 2 years in addition to the £700m already invested.	I'm not sure £3bn is going to be enough to help us weather any economic storm following a Hard Brexit. It's disappointing that the Government are still talking about the prospect of a No Deal; surely it's better to compromise and secure a free trade deal by offering the EU a decent financial settlement than walk off with nothing.	The Chancellor is well within his rights to put money aside in the event that Brexit negotiations break down but I think he's being a bit too hasty. However, if we left the EU without a deal, any short term economic pain will be offset massively by free trade deals negotiated outside the EU. I'm sick and tired of people talking British businesses and the Government down. There's no evidence to suggest there would be a great recession. Remoaners need to get on board with the program now.	£3bn will not be anywhere near enough to help us if we end up leaving the EU without having secured a trade deal. It won't even cover potential extra NHS running costs let alone help people with huge inflation rises. Hammond hasn't even said what he'd spend the money on in terms of Brexit preparation. If we weren't leaving the EU our economy would have probably grown even more and we'd have more money to fund Social Care and Policing, which weren't even mentioned in this Budget!	I understand why Mr Hammond feels the need to squirrel away money for a potential short-term economic crisis following a Hard Brexit but I don't believe it'll come to that. The EU wants to trade with us and they may be willing to compromise to secure that trade deal. Then maybe most of the money can be spent on giving nurses a pay rise or funding Mental Health services in Lincolnshire.
Tax free Personal Allowance Income tax threshold rise from £11,500 to £11,850 from April 2018.	I'm afraid that the Personal Allowance increase isn't going to help young people very much, let alone families. What's going to happen if prices keep rising? It's costing me more money to buy the kids Christmas presents this year. I doubt Mr Hammond has to worry about budgeting for them!	Excellent proposal announcement by Mr Hammond that's going to help Just-About-Managing families across Lincoln. You wouldn't get such a policy measure from McDonnell!	It's a good start I guess but I'd have liked to have seen the allowance increase to £12,000. Maybe next year?!	Wow! Another rise in the Person Allowance will help me save money towards a deposit on my first house, so that's good news!
National Living Wage rise of £0.32 from April 2018.	I'm disappointed by the pitiful rise in the NLW this year. It's not going to be enough to help young people save for a house and my son, who's an Apprentice is only getting an extra 20p an hour.  Why can't young people under the age of 25 and Apprentices be paid the same amount as me or my peers?	I think £0.32 rise was satisfactory. I can't believe those under 25 are still moaning about not being paid the same as those over the age of 25. How do they think small businesses can stay afloat if they start paying the NLW to all employees? As for paying everyone the Living Wage (£8.75) that's a farcical notion!	£7.83 an hour is still a small amount really for working in care homes or doing the cleaning in offices. You hear of people on benefits turning down work because the employer or agency can't pay them more than the NLW. With Brexit happening and people leaving the country, how are businesses going to get the staff to replace them? They're going to have to raise the NLW to a decent amount....why not pay everyone who's not an Apprentice £8.75 an hour?	I know some SMEs would struggle to pay an extra £1.75 an hour to pay the Living Wage but maybe an extra 50p an hour would have been a better offer so workers can prepare for possible food and clothing inflation and still afford to pay the rent.
Abolish Stamp Duty on all homes under £300,000 for first-time buyers	This is all well and good for young people who have managed to club  together the money for a deposit and mortgage but those of us who already have a property and want to move will still have to pay the Stamp Duty. As for private renters, there was little in the Budget to help them. Shame!	I think this is a well thought-through policy that'll help my children get onto the property ladder. Young people should aspire to own a home of their own and the Conservatives are the ones to help them achieve their dreams.	The Tories have once again missed the mark. What happens if demand for homes in Lincoln increases and that pushes up house prices? Those who are looking to move homes rather than buy their first one may end up paying more for the house. That's no good. Plus there's no mention of council housing in this Budget; the Government needs to look after vulnerable people and not just rich people.	This policy announcement couldn't have come at a better time! I'm excited to buy my first house with my boyfriend and the money saved on the Stamp Duty could go towards paying Estate Agent fees or to buy new furniture. First-time buyers needed an extra incentive to purchase and this was it.
£44bn in capital loans to help build 300,000 homes being built by mid 2020s.	We do need to build more homes so that everyone can have a suitable place to live, including people on Housing Benefit. I don't believe the Tories will build 300,000 homes a year and even if they did, most of them would be for people to buy. We need more council houses now, not in the future.	With the massive influx of people from Eastern Europe over the past 13 years, we have ended up in a position where we now have a housing shortage. The loans need to be taken out to build the extra housing but I hope that there aren't many more developments in Lincolnshire. We need to protect our countryside from being over-developed I think.	Housing's a big issue in Lincoln. I know families who are desperate to find an affordable home to rent and it's good that Lincoln City Council are investing in house building on waste land already. I don't know how much of the funding Lincolnshire will get for house-building and I'm not convinced the Tories will ever be able to help build 300,000 homes a year. They never seem to meet their targets on anything else!	More housing in the Lincoln area which would be affordable (and not just to satisfy an increase in students) would be greatly appreciated . I hope Lincolnshire will get some of the capital loan funding but we won't know any details until next year I guess.
Ability for councils to 100% premium council tax on empty homes	I think it's right that the City of Lincoln Council should be allowed to charge a 100% premium on empty homes. There may not be many here but the extra money can help fund bin collections.	I don't really understand why this policy is needed. If a council can already charge a 50% premium, is it that fair to double it just because the home being held for investment purposes?	Homes should only ever be empty for a few months of the year. They need to be maintained properly. If some home owners only buy a property for investment reasons, they should be forced to sell within a year or two. It's like people who buy land for development and they never use it. The Government needs to stop that from happening.	This is a fair measure that should bring in some extra money in Lincoln but I'm guessing the areas which will benefit the most will be in London.
£40m to train Maths teachers and £600 Maths Premium for schools, for every pupil taking A-Level or Core Maths.	It's alright encouraging more young people to take Maths A-Level but not everyone is going to be a Maths genius and we shouldn't neglect the importance of Arts subjects, including English. Let's stop stifling creativity in schools. Where's the extra money for art materials or musical instruments? We need an Arts Pupil Premium.	Maths gives people the core skills they need to be savvy business entrepreneurs. Those who study Maths will earn more in their working lives. Why should they be told to take fluffy subjects Media Studies or Drama when all it teaches them is how to draft a newspaper article or how to use a different accent. Those skills aren't useful in today's competitive jobs market.	While I appreciate the need for more people to be good at Maths, I don't understand how learning geometry or formulas would help me in my job. I guess there are vacancies in engineering but not every young person wants to go into engineering. I agree with Voter A. We need more money for creative subjects to help with social skills and verbal communication.	I can understand the Government's decision to invest in Maths. Engineering firms are struggling to hire young people with the right skills in Lincolnshire and getting schools to encourage more of them to study A-Level Maths and Engineering is important.
8,000 extra Computer Science teachers so there is 1 qualified teacher in every UK secondary school	I guess we all need to be competent at using computers in the workplace so this is a good policy measure.	Young people need to know how to code, how to use computer software packages beyond MS Office. This was a no-brainer policy move.	I never studied ICT beyond Year 9 in school and it never did me any harm in the workplace. I guess coding would be a good skill to learn but I don't think every child should be forced into putting all their effort into Sciencey or Techie subjects.	It's important to have qualified subject teachers in schools and Computer Science should be no exception. Coding skills, formatting skills and graphics skills are all utilised by marketing people in small businesses.
£20m to support introduction of T-Levels in Further Education Colleges	I didn't know what a T-Level was until my friend explained it to me. I think it's good to recognise vocational skills in hairdressing or accounting.	Another great policy decision by the Conservatives. Who said they weren't the party of Education?	As long as the T-Level isn't just another rebranding exercise, this will be good for young people. Colleges need more funding though so they can continue running A-Levels and short-courses and employing good lecturers.	£20m doesn't sound very much for FE colleges but it's only to get the T-Level courses organised. Maybe some of the money will be spent on hiring more teaching staff...I don't know really.
£30m in Digital Skills distance learning courses as part of a National Retraining Scheme (run by the CBI and TUC in partnership with the Government)	I wonder how many people in Lincoln will benefit from this scheme in the future. If it's not advertised or promoted well enough, not many.	A National Retraining Scheme is a great concept and will help older workers learn the digital skills they need to gain good jobs.	I thought the ECDL qualification was meant to help people learn digital skills. Why not fund that instead of designing yet another course and put the money into other projects?	This is a great idea. Nobody should be left on the scrapheap as a result of changes in technology. It's just going to take a lot of marketing of the Scheme and encouraging people to see it as useful.
Fuel Duty rise cancelled again.	Good news but the cost of car insurance will probably offset any benefits from this and if petrol prices rise, I may start taking the bus to work.	I don't drive currently so the measure won't affect me. I know my friends are quite pleased they won't be paying more for petrol. I read in the Sun ASDA reduced the cost of petrol by 2p after the announcement so maybe prices will reduce across the board.	The Tories are frightened of raising the Fuel Duty because rural voters may be more tempted to abstain from voting or voting for another party in protest. We need more money to fund our public services and part of that extra funding could come from a small rise in Fuel Duty.	I'm glad that the Fuel Duty rise has been cancelled! The money saved I can put towards food and clothing.
Duty on wines, spirits, beer and most ciders has been frozen but "white cider" duty will increase.	As a wine and spirits drinker, I'm happy that the price won't be going up as the result of Government duties.	Cheers! The freeze on alcohol duty should benefit our local pubs.	I don't drink that much but nobody's going to be that unhappy about a duty freeze on alcohol.	My brother drinks white ciders so he's a bit miffed he'll be paying more. I'm glad there isn't going to be an increase on wines but I'll be paying more for my cigarettes.
£2.3bn extra for research and development (Science, Technology, Mathematics and Engineering).	The government wants to support science and technology so I guess this isn't much of a surprise. Whether it should be used to build electric cars or in AI is up for debate. I think the investment amount is too high when schools and hospitals need more funding now.	Britain has always been an innovative country so I'm pleased more money will be used to support projects.	Where's the extra funding for Primary Schools in Lincoln? Where's the extra funding for SEN support staff for pupils with learning difficulties? What about funding for Arts based R&D? We don't need to fund electric cars when people are shivvering cold on our streets and in their homes. The Government has got its priorities wrong yet again.	£2.3 billion seems a huge amount to waste on “happy go lucky” science projects. We need more investment in apprenticeships and internships to make them more accessible to working class kids. We need to spend more money on improving IT skills for working class employees too!
£385m investment in digital infrastructure. (5G mobile networks and Superfast Broadband).	Digital infrastructure programme do need to be encouraged but was giving 100% business tax relief to digital firms for fibre cabling the way forward? It seems Hammond and May want to appease big business rather than improve the lives of working class Millennials in the countryside. Will the initiatives  be completed by 2020? I'm not convinced.	Digital coverage needs to be vastly improved in Lincolnshire. I need to be able to process orders regularly throughout the day and that means having continuous internet connectivity pretty much 24/7. I doubt McDonnell would have invested in 5G....Labour doesn't seem to have a technology plan....not a workable one anyways.	I can't see why more money needs to be pumped into internet coverage in the countryside. So much has been given already....why can't the telecoms companies stump up more cash?	Great news. I hope Labour supports the funding decision because digital coverage needs to improve in rural areas. It doesn't just help farms and rural based SMEs to connect with their customers faster and more securely but will also allow rural people access to better streaming of films and to listen to podcasts.
£1.5bn to help rectify Universal Credit concerns, 2 weeks of extra Housing Benefit for new UC claimants and access to a 100% advance UC payment within 5 days of applying for UC.	Hammond should have listened to concerns and paused the UC roll-out. Vulnerable people are at risk waiting for the money to come through and an advance needs to be paid back. Now they'll be a 100% advance available next year means that people will need to pay 1 month's worth of money back within a year. If they're not working, how will they do that?	The benefits system needed to be reformed and the Government have been taking action to reform it. If people aren't happy about UC, they should get up in the morning and look for full-time work. Extra Housing Benefit payments will help most people stay in their homes whilst their claim's being processed. The UC benefit is too generous already but the Government wants to please skeptics and have caved in.	It's just not enough money. The Government won't help disabled people or homeless people with such small changes. I want to see the UC scrapped and the Government apologise for wasting money on it.	I think the UC system is a good idea in theory but more work needs to be done to plan its roll-out. Housing Benefit should be covered for the whole period so people are not threatened with eviction. Advance payments are OK in 12 months to pay back if you're working or find work but what if you'll never be able to work? The Government hasn't thought it through enough.
26-30 Railcard Scheme saving a 1/3 on rail fares from Spring 2018.	This is good news for 26-30 year olds who use the train to get to work but I guess that's not many people. We need to reduce rail fares for everyone. What's the Government doing to facilitate that?	I'm not really fussed by this policy and it's just a gimmick to get more young people to vote Conservative.	Rail fares are too high for everyone without a discount railcard because the railways are in the hands of private companies who just want to make more and more profit. Labour would work to renationalise the railways and encourage companies to reduce rail fares quickly following the next election.	I use the rail card at the moment to get to work so the extension will benefit me directly but very few of my friends travel by train to get to work.
£2.8bn to fund the NHS in England over the next 3 years including £338m to help NHS trusts cope this winter	Our NHS needs funding to ensure essential frontline services can be maintained. They asked for £4bn and only got £2.8bn. Where was the money to give our amazing nurses a pay-rise? They did it for prison and police officers!	We can't keep throwing money at NHS managers without expecting them to make their NHS Trusts more efficient. Where's most of the money going? They need to stop paying agency staff and focus on recruiting more permanent staff and if they can't do that then maybe they're in the wrong job.	It seems like the NHS has been given the bare minimum funding it needs to operate. This Government has no idea how to plan for the future of schools or hospitals (only Brexit). There was no money for Social Care either. I thought there would be at least a cap on care costs.	I don't think enough money has been given to the NHS for them to cope with demand. I'm worried that waiting times will increase. My GP surgery's already struggling. I can understand why nurses are upset about not receiving a pay rise. My friend has had to use a food bank just a week once. It was a humiliating experience for her.
Best Policy	Funding for Maths and Computer Science Teachers	Freeze on Fuel Duty	Funding for Maths and Computer Science Teachers	Funding for Maths and Computer Science Teachers
Worst Policy(set of policies)	Universal Credit	Council Tax Premium increase on empty homes	Brexit funding	Universal Credit
Voting Intention as of 27/11/2017	Labour	Conservatives	Undecided	Lib-Dem

Thoughts on the NHS England Gender Identity Services For Adults Consultation 2017

Gender Identity Services (GIS) in England are currently inadequately funded and staffed to meet the needs of trans and non-binary patients. Trans healthcare was one of the key areas of concern highlighted in the Trans Inquiry findings published by the Women and Equalities Committee last year (you should read the evidence submitted to the Trans Inquiry if you haven't already because it lays out the extent of current issues facing trans, non-binary, genderfluid and genderqueer patients when trying to access and when accessing GIS: https://publications.parliament.uk/pa/cm201516/cmselect/cmwomeq/390/39008.htm). It was clearly stated in the final Trans Inquiry report that the Women and Equalities Committee believed that the NHS was "letting trans people down" and failing to adhere to the Public Sector Equality Duty that they are mandated to follow under the terms of the Equality Act 2010. This is backed up by the findings of the Unhealthy Attitudes Survey carried out by Stonewall in 2015 (http://www.stonewall.org.uk/sites/default/files/unhealthy_attitudes.pdf) which was completed by 3,001 health and social care professionals. 28% of respondents to the survey stated that they did not feel that doctors were confident enough to respond to the specific care needs of trans patients, 9% were aware of colleagues experiencing discrimination or poor treatment because they are trans and 7% of respondents openly stated that they would "not feel comfortable" working alongside a trans employee.  Transphobic attitudes held by some GPs, nurses and other healthcare professionals needs to be stamped out, through the beefing up of HR led equality and diversity training. With regards to training, the Unhealthy Attitudes Survey found that 72% of respondents had not received any training on the specific healthcare needs of LGBT+ people; only 23% of respondents had received training on the legal rights of trans service-users. Also, only 27% of respondents said they'd received training on the legal rights of trans colleagues. There's definitely room for improvement.

The overall recommendation made by the Women and Equalities Committee was for the NHS to conduct, complete and publish a review of trans healthcare generally. There is also a  specific need to improve GIS, recommending that GIS be separated from mental health services and review their"treatment protocols", including the "Real-Life Experience" requirement to have access to surgery. However the Women and Equalities Committee refused to advocate for "on demand services" which made me think that there is still a general reluctance to accept that trans and non-binary people know their own mind and should have a larger stake in talking through procedures necessary to help them to lead their own lives.

NHS England have realised that GIS provision for adults needs to be improved and so have come up with a plan that they believe will make GIS more accessible and efficient. They have put these plans out to consultation and are encouraging trans (and non-binary) patients along with organisations such as Stonewall and GIRES to respond to their plans directly. So I'll offer a few of my own thoughts in this blogpost and encourage readers to consider responding to the proposals whether through YouTube videos, podcasts, blog posts or via NHS England's webpage (https://www.engage.england.nhs.uk/survey/gender-identity-services-for-adults/). It must be noted that this consultation is designed to bring in measures to replace the interim set of rules that were created in 2013 and that there have been 2 attempts to replace these rules which have not managed to progress. The 90 day consultation period (ending on the 30th September 2017) should allow for a range of voices to contribute their opinions about the proposed specifications and hopefully NHS England shall listen and make any necessary changes suggested in feedback.

The Consultation Document: 

Firstly, the Consultation Guidance from NHS England admits openly and honestly that GIS for adults need to improve. That includes looking at data collection, creating "quality and outcome measures", increasing capacity within GIS so that more patients can have access to treatment, addressing workforce constraint issues (the lack of specialist nurses, sexologists etc which is apparently primarily the concern of Health Education England), equalising "access to specialised interventions", addressing "infrequency and number of appointments" and revising administrative procedures. I'm glad that NHS England have identified these specific service improvements to focus on but as with everything NHS related these days, I wonder how much it will cost to implement these suggested improvements in England and whether NHS England are truly brave enough to ask for a specific increase in funding to allow these improvements to GIS to happen. No budgetary breakdown is offered in the consultation document itself but I am aware that an additional £4.4m had been invested in 2015/16 specifically for GRS in England. I'd like to know how much is estimated to be invested in GICs generally during the 2017/18 financial year with a breakdown of how much money has been allocated to each GIC for the 2017/18 financial year.

I am delighted to read that the consultation document makes it crystal clear that NHS England will not fund or allow providers of GIS to engage in the promotion of reparative therapy (aka conversion therapy) in any way. The non-surgical specification states that "the practice of conversion therapy is unethical and potentially harmful" and that "conversion therapy" is an umbrella term that includes any "therapeutic approach, or any model or any individual viewpoint that demonstrates an assumption that any gender identity is inherently preferable to another which then aims to get a patient to change their gender identity or suppress it". I hope that all NHS professionals working in GIS can agree with this declaration and that those working in the NHS more generally can regardless of their own private views.

As I've noticed with other recent NHS Consultation documents, there is a desire for NHS services to use advanced technological tools to help in the provision of advice and guidance for patients. I can see that for some trans and non-binary patients, Skype consultations with specialists could be appropriate, especially to discuss the effectiveness of current treatment plans. However, patients who are less comfortable with remote based conversations must still have access to face-to-face discussion appointments.

Referrals for gender reassignment surgery (GRS) on the NHS should on the whole be made through the GIS, provided that the multi-disciplinary teams at the GIS are in agreement that the individual is physically fit to go through GRS. Risk assessment should be the same as for any major form of surgery and should not over-focus on a trans person's "social issues" (those issues shouldn't matter anyways!) The GIS team must listen carefully to the needs of the patient and allow them to trust their own judgement (i.e. on an informed consent basis).

I understand that other NHS professionals who are not specialists (e.g. GPs) may feel reluctant about referring a patient directly for treatment, whether non-surgical or surgical. Training should be provided through Continuing Professional Development schemes to equip GPs with the knowledge they need to support a trans or non-binary patient throughout the initial referral process. My local GP was extremely proactive in finding out about access to my local GIC in Nottingham, ensured that they carried out all of the baseline tests within a fortnight of having had an initial meeting with them and then made the referral to Nottingham only a few days after the results of those baseline tests. My GP treated me with respect, non-judgement and listened to what I had to say, the same attitude that they would have had with any other patient. My GP may have only had a half-hour time slot to see me in (which was pre-planned by the surgery after I made the phone call to discuss GIC access; the receptionist on the phone was courteous and made no judgement). The nurses were equally empathetic; I remember during one baseline test I had to take off my vest and I was very nervous about doing this (I've never undressed in front of someone to that level since before secondary school) but the nurse carrying out the test put my mind at ease and never once referred to me by incorrect pronouns or tried to insinuate I was an "attention seeker" or "misguided" words you read on social media (luckily for me it's a rare occurrence). The service my local GP surgery provided was exemplary.

There is an increasing belief amongst LGBTQIA+ equality groups such as UK Trans Info that self-referral for GIS should be the norm because there is no real need for a GP to be involved in the initial referral process because it may be the case that GPs who have a bias against non-binary patients in particular may not carry out the referral to a local GIS despite an expressed wish by the patient on several occasions. There needs to be reassurances made by organisations such as the General Medical Council, British Medical Association General Practitioners Committee and The Royal College of General Practitioners that any unwarranted obstruction in access to service would lead to a GP facing disciplinary action as it may contravene the Public Sector Equality Duty placed on GP services by the Equality Act 2010. This should satisfy most concerns regarding the referral process.

I wonder whether private clinics should be necessarily ruled out from providing GIS on the NHS, especially if those private clinics have experienced professionals who deliver GIS on a regular basis. That being said I have concerns about increasing outsourcing of services to private sector organisations; Labour voters would not be happy to see more NHS funding being used to fund private sector treatments on a regular basis. What is important to remember here is that NHS Clinical Commissioning Groups (CCGs) should decide what happens in cases where a patient who has been able to afford private surgical treatment then loses their job and can no longer afford to pay for further treatment. Should those patients be automatically ruled out from consideration? I would argue that private patients should be allowed to access a NHS pathway of surgical treatment provided funding is in place from local CCGs to fund it. No patient should be turned away because they started their transition privately.

I agree with the proposal put forward to allow 17 year olds to access adult GIS in England and for the Gender Identity Development Service for Children and Young People (GIDS) to only accept referrals in future up to the age of 16, provided there is capacity in the system to allow 17 year olds to be seen swiftly. 17 year olds have reached past the age of consent (which is 16) and should have access to medical treatment (e.g. hormone replacement therapy) without facing unnecessary delays. I am concerned by the proposal that GIDS should remain responsible for the care of young people who may have "complex or psychosocial conditions" (it's not clear which conditions are included under NHS England's definition in the proposed specifications but it includes conditions such as schizophrenia, obsessive compulsive disorder and anorexia) which are thought to currently prevent them from pursuing physical interventions. I disagree that all psychosocial conditions must be included within this provision- for example, I am not necessarily convinced that a young trans person with ADHD or anorexia should be prevented from considering surgical treatment unless it could be proved beyond reasonable doubt that such treatment would exacerbate the problem. I think that these young trans and non-binary patients should take part in the decision making process when it is clear they have the mental capacity to be able to engage in the process.

Family members should only attend appointments when a trans or non-binary patient has specifically requested they attend with them; clinicians should not be allowed to demand a family member attend an appointment, even if they attempt to justify this on "emotional" grounds. A family member should never be asked to consent on behalf of the patient; a patient who has reached the age of consent (16) should be trusted to make their own decision. Never pressurise a trans or non-binary patient to bring someone with them; they may not have talked about their change in gender identity with family or friends before attending the GIC.

I am sympathetic to the proposal to reduce the number of clinical opinions needed to approve GRS to 1. I understand NHS England's concerns that a Registered Medical Practitioner should be the main clinical opinion sought during the process because they will have access to the patient's current and past hormone therapy data and be able to give their opinion regarding suitability for surgery. However I am also interested in hearing more about the proposal put forward to by the Clinical Reference Group for Gender Identity Services which states that no Registered Medical Practitioner opinion is necessarily needed because the specialist surgery team would examine patient history once they have been admitted into the unit.

I am extremely pleased to note that there is a firm commitment to ensure that all GIS will be available to non-binary and gender-fluid patients should they wish to have access to them, including surgical interventions.  Patients definitely have the right to self-expression ("personal autonomy") of their gender identity and presentation/ expression and also be referred to by the correct pronouns and names throughout the process. Regardless of these positive changes, it must be recognised that not every non-binary or gender-fluid person wants to have hormone treatment or surgery and should still have the right to self-identify and legally gain a Gender Identity Certificate without having to go through GIS or to "prove their identity" by going through a panel. Those legal changes are going to be discussed once the results of the national LGBT survey commissioned by the Secretary For Women and Equalities, Justine Greening, have been collected, collated, analysed and evaluated. I think we will all be interested in those findings when they are published (I am presuming this will be early 2018 at the latest).

The 12 month "Lived In Experience" requirement for GRS does seem rather an outdated concept to me personally. Most trans patients will have spent more than 12 months in their acquired gender before they even get to the GRS consultation stage and any consequences that come about as a result of GRS would only occur once the GRS has been undertaken. There is also no way of determining an objective assessment of  what the typical "Lived in Experience" is for a non-binary person so non-binary patients who wish to undertake GRS may be barred from accessing GRS based on not fulfilling the current requirement; this contradicts NHS England's stated aim of making GIS equitable for non-binary patients.

It's great to read that there has been a call for applications for more research on GIS from the National Institute for Health Research (June 2017). Improving the objective evidence base may mean that GIS will be commissioned that better meet the needs of patients and if some of the final reports are then made available in the public domain, we will all have a better understanding of how to provide the best level of care and support to trans, non-binary, gender-fluid, genderqueer and agender patients as well as helping to promote self-care where appropriate. That can only be a good thing.

As of yet I am undecided regarding the best prescribing arrangements for hormone replacement therapy for trans, non-binary genderfluid and genderqueer patients. At the moment, the specialist team based at the GIC will assess a patient's needs on an individual basis and then pass on the information to the patient's GP who then take full responsibility "for prescribing and administering the medicine (and to perform standard pre-treatment physical monitoring and laboratory investigations)". There are 3 alternative models that have been suggested regarding the prescribing arrangements for trans, non-binary, genderfluid and genderqueer patients. These are:

• "A specialist team based at the GIC being responsible for issuing the first prescription" with the data relayed to the patient's GP who takes on responsibility for prescribing then onwards (Option B)
• A specialist team based at the GIC issuing prescriptions for 1 year "or until the patient's endocrine treatment has been stabilised" with the GP prescribes from then onwards (Option C)
• A specialist role being developed for GPs at a Clinical Commissioning Group level (or Sustainability and Transformation Plan level in the future if they get approved) with that dedicated GP issuing prescriptions "for all relevant patients in the area on the recommendation of the specialist team" (Option D). 

UK Trans Info (who have far more collective experience of advocating for better trans, non-binary, genderfluid and genderqueer healthcare than myself) have argued that the best model for providing HRT would be Option D because it "allows for the most efficient treatment of trans people in an area without requiring excessive amounts of travel" (http://uktrans.info/nhsconsultation2017). The consultation document does flag up the concern that some trans, non-binary, genderfluid and genderqueer patients may be asked to travel to a different GP practice than their own for the HRT, which may be difficult because they may not have the money available to allow them to travel, especially if they are unemployed. I cannot see a situation where the NHS would be able to routinely help with the costs of travel incurred, especially under the current funding constraints.
However, it must be pointed out that travelling to the local specialist GP's surgery would probably be cheaper and less time-consuming than constantly travelling to the GIC for a year (Option C). The consultation document does also point out that there may be issues trying to attract local GPs to consider taking up the specialist role, which "risks an inconsistent and inequitable approach to care"; will there be enough specialist GPs in rural counties such as Lincolnshire? Lincolnshire would need more than one specialist GP with it being the second largest county in England; one would need to be based in Lincoln to cover North and Central Lincolnshire with another based in Grantham or Boston to cover South Lincolnshire. There may be an issue with succession planning in the future too; what would happen if a specialist GP decided to relocate or retire and there aren't any qualified specialist GPs to take their place to allow for a seamless transition in prescription care? Patients would not accept a lengthy delay in receiving their HRT. 

That being said, Option D could be a blueprint for helping to develop local expertise and GPs in the local area may learn "experientially" about trans healthcare and endocrine management, which would be very beneficial in the long term; in fact, as specialist GPs become more experienced, they may be able to "take on more of the clinical services currently provided by GICs" but it is acknowledged that more funding would be needed to facilitate this decentralisation of services. 

UK Trans Info has pointed out that there may be long waiting times for patients and have argued that GPs should be able to give out bridging prescriptions if it takes more than 18 weeks for that specialist to issue the first prescription; the General Medical Council guidance issued last year recommending that GPs offer bridging prescriptions in exceptional circumstances (if they have been self-medicating or to reduce the risk of self-harm or suicide). UK Trans Info agrees with the GMC guidance and believes that any trans, non-binary, genderfluid, genderqueer or agender patient that has been self-medicating when they approach their GP should not be told to stop as is currently the case; instead there should be a bridging prescription made available, with regular monitoring of those trans and non-binary patients who have self-medicated in the past. Not ever GP will feel comfortable with the idea of offering bridging prescriptions without seeking specialist advice and guidance. Zara Aziz, a GP partner in a practice based in north-east Bristol wrote a recent article in The Guardian where she argued that whilst GPs are specialists "in prescribing and monitoring in many clinical areas that ...(they) commonly encounter or that...(they)...have developed an interest in", they do not have such awareness with regards to giving holistic care to patients and it could lead to an increased risk in the number of "complaints and litigation against family doctors", pointed out in guidance provided by the British Medical Association's General Practitioner Committee. Dr Azis argues that handing over most of the responsibility for specialised care to GPs in regards to GIS could lead to other specialised care responsibilities being given to GPs, stretching their time and money further. Dr Aziz wants to see the NHS "commission a robust and accessible GIC locally that can support patients and GPs alike" which would have a multi-disciplinary team in place to provide a holistic service.

I think it is important that specialists make it crystal clear to patients that they may experience a loss of fertility and that they may be able to freeze sperm or eggs but only if their local CCG agrees funding for this; patients cannot demand this service at the moment and it is unlikely that funding will made available in every CCG any time soon.

It's pleasing to see a requirement in the specifications that surgeons must perform a minimum of 20 procedures a year that have been commissioned from the provider and that surgeons are required to demonstrate evidence of Continuing Professional Development and engage at least once a year with their fellow surgeons to share best practice. This group of surgeons will then publish an annual report with data on caseload, outcomes and any complications that have resulted from surgery.

If a trans or non-binary patient requires treatment for complications that have arised as a result of surgery will be able to have treatment provided for up to 18 months after the surgery has taken place; the original surgeon will perform the new surgery.
If a patient does not want to continue treatment with a particular surgeon, they will be referred by the surgeon directly to another surgeon working in a NHS England commissioned surgical unit. The choice of surgeon will be discussed and agreed with the patient.

The Equality and Inequalities Impact Assessment: 

The Equality and Inequalities Impact Assessment identifies a number of areas that have been addressed by NHS England in order to improve trans and non-binary patient care:

• Front-line staff need training to be able to treat trans and non-binary patients with respect, including making sure that trans patients are not placed on the wrong sex ward in hospitals and are not excluded from screening programmes. NHS England have decided to "undertake an initial scoping and feasibility study" to address concerns, focussing on "non-specialised services such as gynecology and voice and communication services" that form part of the NHS pathway of care within NHS England's service specification. The data and recommendations made as a result of carrying out this project will then be used to assess how changes can made "across NHS services more generally".
• The proposed specifications do not have an upper age limit for non-surgical and surgical inventions which means that any patient who wishes to be referred to a GIC should be able to receive treatment when the specialist team prescribes it.
• Patients with communication difficulties as a result of co-existing complex physical or mental health conditions or as a result of a learning difficulty (I prefer the term difference) will require additional support from GICs and from their GP. The EIA makes it clear that in both specifications, a tailored individual treatment plan will be provided and allow for "additional assessment consultations" and "additional support services" when appropriate.
• The EIA confirms that patients with a Body Mass Index (BMI) of more than 30 (for genital surgery) will be required to lose weight unless a surgeon has approved surgical invention once a risk assessment has been carried out.
• Trans patients with HIV would have "consistent access to the range of available interventions" which would lead to "more timely assessment, diagnosis and treatment".
• A patient's history of substance misuse would be a factor in determining access to treatment; those with a current addiction to non-prescribed drugs and alcohol it would seem would find it more difficult to access treatment but it's not clear from the consultation document how long a patient would need to be "clean" before being allowed to access non-surgical and surgical treatments.
• There is an under-representation of BAME trans and non-binary people attending GICs and I agree with the EIA conclusion that GIS must be delivered in a culturally appropriate way. I hope that NHS England will take the time to consult with patients and organisations representing the trans and non-binary BAME community to come up with specific recommendations as to how GIS can be made more accessible, including designing training for frontline healthcare professionals to follow. It is good to see NHS England make a specific commitment to improving their data collection procedures to ensure full compliance with the Equality Act Public Sector Duty.
• It's interesting to note from the consultation document that the Trans Mental Health Study (2012) found that most trans patients have no religious affiliation (62%) but out of the remaining 38%, 20% of trans patients identified as Christian. Data Collection carried out by NHS England from GICs in 2016 had the number of patients who had no religious affiliation at 61% and those who were Christian at 21%. Only 35% of patients filled in the "Religion and Belief" field. Despite this, there must be Chaplaincy services available to those trans and non-binary patients who require "pastoral or spiritual care" regardless of their religious belief.
• The proposed specifications should not discriminate on the basis of sexual orientation and frontline healthcare professionals must not pry into a patient's sexual history because it is irrelevant for non-surgical and surgical treatment processes. Where a patient actively chooses to disclose their sexual orientation, this information must be kept strictly confidential.
• GIS must be inclusive and accessible to patients who may not be registered with a GP. It can be difficult for certain patient groups to register with a GP; e.g. a homeless patient has no fixed address and a sex worker may have no proof of address or identity and may be excluded from registering with a GP based on this. NHS England believes that patients must be registered with a local GP because they are currently best placed to "offer healthcare support", prescribe drugs and monitor treatment, especially once "contact with specialist teams has reduced or come to an end". They reiterate that GP surgeries cannot refuse to register a patient because they do not have personal information to hand (there is no statutory requirement to request this). Therefore, patients currently not registered with a GP should be encouraged to register if they wish to access GIS.

The consultation document also identifies other areas NHS England needs to take into consideration. Many trans and non-binary GIS patients have stated publicly that waiting times for initial appointments are far too long. For an initial appointment with Nottingham GIC for example, I was told that 18 months was the standard waiting time and since I was referred in April 2016, I will probably not receive an appointment letter until early 2018 at the earliest. These waiting times are in breach of the NHS Constitution but NHS England insists that the proposals made in this specifications will go some way towards addressing the waiting time issue and that they will focus on recruiting more specialist staff in the future to relieve pressures. James Palmer, in his first blog as the Senior Responsible Officer for GIS (https://www.england.nhs.uk/blog/we-are-meeting-concerns-on-gender-services/) states openly that the 18 Week Referral to Treatment standard will be monitored "throughout the entire trans pathway" with "regular consistent reporting" beginning from 2018 which will allow for "absolute transparency about waiting times".

NHS  England also noted in February 2016 that they had a "shortage of suitably qualified staff" (http://www.bbc.co.uk/news/uk-england-35605956) but recruitment and retention of talent is flagged
up as a continuing issue at the beginning of the consultation document. Unless NHS trusts find a way of encouraging more qualified staff to join English GIS, waiting times may remain stubbornly high.

The consultation document doesn't specifically address access to services for trans and non-binary patients who are in the criminal justice system. Current evidence states that trans and non-binary prisoners are "routinely segregated" on secure prison wards and denied gender-affirming products whilst in prison which means they are less likely to fulfill the current "Lived In Experience" requirement for surgery. The Department for Justice released guidance (Prison Service Instruction) to prisons on the issue of access to healthcare for trans, non-binary and intersex prisoners which was issued in November 2016 and which came into force on 1st January 2017 (https://www.justice.gov.uk/downloads/offenders/psipso/psi-2016/PSI-17-2016-PI-16-2016-AI-13-2016-The-Care-and-Management-of-Transgender-Offenders.docx). The policy specifically states: "Establishments must ensure that prisoners who have been diagnosed with gender dysphoria have access to the same quality of care (including counselling, preoperative and post-operative care and continued access to hormone treatment) that they would expect to receive from the NHS if they had not been sent to prison." If a prisoner has attended a GIC and has been receiving non-surgical treatment and signals their desire to carry on with their treatment, "it should be continued until the prisoner's gender specialist has been consulted on the appropriate way to manage the prisoner's treatment unless the doctor working in the prison has reasonable clinical grounds for not doing so."

The policy also states that access to private health clinics for prisoners is restricted: "there must be sound and demonstrable clinical reasons for allowing access to private health services. There must be evidence that this will improve the health of the individual and is not based on uninformed personal choice".

When a trans, non-binary or intersex prisoner signals an intention to begin hormone replacement therapy for gender dysphoria, the prison health care team have a responsibility to inform the relevant Clinical Commissioning Group and "request a point of contact for liaison". When a prisoner wishes to undergo GRS, the prison GP must liaise with a consultant directly to accept advice from them. The Governor may also "prepare a report to the consultant as to the practical impact within a prison context" of the prisoner recovering from GRS. The consultation document and specifications do not give guidance on how the referral process for trans and non-binary prisoners may differ as a result of a prison Governor's report intervention, for example. 

What's been made clear in the consultation document is that NHS England will not provide surgical and non-surgical treatment to patients whose presentation "primarily relates to intersex conditions" (aka disorders of sexual development) who have expressed a desire to have surgery through the future GIS. This may be because NHS England believes that a standard treatment pathway may not fully take into account specific needs of intersex patients. UK Trans Info have argued that intersex patients should have full access to non-surgical and surgical treatment when they have expressed a wish to undertake such treatment but that they should not feel forced or coerced into undertaking any treatment correctively. They also point out that whilst not most intersex patients will not identify as trans, there are some intersex patients who do publicly identify as trans or non-binary; are they going to be denied access to non-surgical and surgical treatment entirely? If such services are not going to be provided through GIS, where are trans and non-binary intersex patients going to have access to non-surgical and/or surgical treatments? When will NHS England unveil this alternative pathway? How much longer would trans and non-binary intersex patients have to wait to be seen by specialists?Would specialists in the alternative pathway  have the contextual knowledge to treat trans and non-binary intersex patients with true respect and dignity? These questions need to be answered and I think a review of intersex patient healthcare is timely and necessary so that healthcare professionals and the public alike understand clearly what will happen.

An interesting response to the NHS Consultation : 
Not every organisation is in favour of engaging with the NHS consultation; the main reason being that they do not believe that the current GIS system is acceptable in any way whatsoever. The Edinburgh Chapter of the Action On Trans Health organisation have released their own "Trans Health Manifesto" (https://edinburghath.tumblr.com/) designed to revolutionise the way that trans and non-binary healthcare is delivered: "we demand nothing less than the total abolition of the (Gender Identity) clinic, of psychiatry and of the medical-industrial complex". Instead, there would be:

• universal access to hormones and blockers through free prescriptions so that trans and non-binary patients can self-medicate
• access to therapy at drop-in clinics or through self-referral
• anonymous blood tests with equipment being delivered through "post or at drop-in endocrinology clinics"
• an end to surgical prerequisites with access to tailored surgery, including access to reversal surgery on demand
• resources for hair removal of any kind 
• voice coaching that doesn't "coerce us to alter our voices in ways we do not express a need for"; such coaching should respect accents 
• medical training so that self-medicating trans and non-binary patients can carry out research in order to "improve the quality of medications" and "reduce negative side-effects in the long term"
• create research centres and libraries which are organised for and by trans patients with "full funding" being made available for any projects carried out

The initial concern here again would be with funding; how much would it cost to fund the surgeries required, the research collectives and the medical training. Even with the money saved from shutting down GIS (which I am concerned about), I suspect there will be not enough funding available to meet such demands. There are other aspects of the vision document which do not sit well with me, including revoking the medical licences of GIS staff, who are on the whole extremely hard working and passionate and whose knowledge and skills would be needed to help direct training to aid research anyways. There are other elements of the vision statement that I agree with, including the mandatory education about trans and non-binary issues that should at least involve trans people and organisations and the demand for accessible, high quality housing  for trans and non-binary people who find themselves unemployed or on in-work benefits. Anyways read the document for yourself; it's thought provoking! 

Conclusion:

The two draft specifications that have been offered by NHS England are broadly speaking to be welcomed; there are proposals which will help to provide better standards of patient care for trans, non-binary, genderfluid and genderqueer patients. There is a commitment to reviewing waiting times, a commitment to treating non-binary, genderfluid and genderqueer patients with respect and dignity and for most 17 year olds to access adult GIS so they can begin HRT as soon as possible. There are issues with the specifications with regards access to treatment for patients who have a mental health condition (there needs to be clarity regarding what mental health conditions would necessarily preclude a trans, non-binary, genderfluid or genderqueer patient from being able to go through HRT or GRS). There needs to be much more clarity regarding intersex patients who also happen to be trans or non-binary and their access to GIS. There needs to be a review into surgical procedures that can be offered on the NHS, including the ability to access corrective surgery including when complications have arisen after the 18 month time-frame. The Lived-In Experience requirement needs to be reviewed for effectiveness; if it's impossible to quantify what constitutes what is a "normal" experience for a non-binary person, there's no way a non-binary patient can fulfill the requirement and can therefore not gain access to GRS should they require it. Equally, there is no real way to be socially a man or woman that isn't rooted in gender stereotypes; a trans man can still wear dresses occasionally if they choose even if this isn't typical of all men and this should not impact in any way the validity of that trans man.  As UK Trans Info have pointed out, the Lived-In Experience requirement may also be seen as patronising; do trans people need to be taught about the consequences of transitioning? Prescribing service provision needs to be agreed with the consent of all stakeholders involved; Option D may be the ideal but there may be pushback from CCGs in certain areas of the country who believe there can be no special GPs allocated to become specialists in prescribing and offering specialist care and support to patients. I look forward to seeing the results of the survey and conclusions and recommendations drawn and hope that NHS England will be proactive in reviewing and addressing areas of concern within the specifications. Then perhaps we will begin to see GIS that truly provides the highest standards of specialised and effective patient care across England.