GP and GIC coordination: how the referral and monitoring works

What the system is supposed to look like

The intended pathway runs in a clear sequence. You go to your GP. Your GP refers you to a gender identity clinic, a specialist NHS service that assesses and recommends treatment. Once the GIC has seen you and formed a clinical view, it writes to your GP recommending a treatment plan, which usually includes hormones, monitoring, and follow-up intervals. Your GP then takes on the prescribing and routine blood-test monitoring under what is called a shared-care agreement. The GIC retains oversight, adjusting the clinical plan when needed, while the GP manages the day-to-day prescribing.

On paper, it is a sensible division: specialist knowledge sitting with the specialists, routine prescribing sitting with the person who sees you most often. The problem is that the paper version and the lived version diverge almost immediately for most people, and they diverge in ways the system does not acknowledge or repair.

Where the referral stage goes wrong

The first fracture point is the referral itself. In England, NHS gender identity clinic waiting lists have run to several years. During that wait, your GP holds your referral but often has no active role. No one is monitoring your health in relation to gender, no one is checking in, and if you move to a new area and re-register with a different GP, the referral may not transfer cleanly. It can, in effect, disappear.

Some GPs are not clear on whether they are required to refer. They are. Under NHS England commissioning arrangements, a GP who declines to refer to a gender identity clinic without clinical justification is not following correct procedure. If your GP has refused, you are entitled to ask for the clinical reason in writing, and you can ask to be referred to a different GP within the practice, or raise a formal complaint. The NHS constitution gives you the right to be referred to a specialist of your choice where one is commissioned to provide that service.

This does not mean the referral gets you seen quickly. It means it gets you on a list. The wait is the wait, and that is the reality rather than something a referral solves. What it does is start the clock, and the clock matters.

What the GIC actually does with a referral

Gender identity clinics vary in how they work. Some operate a multi-disciplinary team model, where you are seen by a psychiatrist, psychologist, and endocrinologist at different points before any recommendation is made. Some have moved toward a more streamlined informed-consent approach. Either way, their function is assessment and recommendation, not long-term ongoing prescribing in most cases.

When the GIC writes to your GP, that letter is a clinical recommendation, not a prescription. It sets out what treatment it considers appropriate and usually invites your GP to prescribe under a shared-care protocol. The protocol, when it exists, specifies what the GP monitors, how often, what blood values they are looking for, and when to refer back to the GIC. Most major GICs have published or will share their shared-care guidance on request.

When GPs refuse shared-care agreements

This is where most people hit a wall. GPs are not legally required to enter a shared-care agreement, and a significant number refuse. The reasons given vary: lack of training, lack of confidence in prescribing hormones for trans patients, practice policy, or clinical governance concerns. Some CCGs, now integrated care boards in England, have issued blanket guidance discouraging shared-care for gender-affirming hormones, which makes individual GP compliance harder even when the GP is willing.

If your GP refuses, you have a few options. You can ask your GP to explain in writing which aspect of the shared-care protocol they are declining and why. You can ask whether another GP at the practice will accept it. You can contact the integrated care board to ask whether there is commissioned support available for GPs who are willing but uncertain. You can also ask the GIC whether it has relationships with any local practices known to accept shared-care referrals, though in my experience this information is not always offered proactively.

What you cannot currently do, in most of England, is simply move on and access the same care without the GP's cooperation on the NHS pathway. That gap is real and it causes harm. People are left on hormones they sourced themselves, without monitoring. People stop treatment because they cannot access prescriptions. People's health deteriorates in ways that are entirely preventable.

The monitoring gap: who checks your bloods?

Even when shared-care does operate, the monitoring side is often the weakest link. Hormone monitoring for trans patients typically includes blood tests at regular intervals: checking hormone levels, liver function, full blood count depending on the hormones used, cardiovascular markers, and bone health over longer periods. The GIC sets the initial intervals; the GP carries them out.

In practice, many GPs do not proactively call patients in for these tests. People who know what they need can request them. People who do not know can go months or years without monitoring that should be routine. If your GP is not prompting you, and you are on hormones, it is reasonable to ask your GP directly: which tests does my shared-care protocol require, at what intervals, and can I book them now?

If your GP does not have a copy of the shared-care protocol, you can ask the GIC to send one. If the GIC is unresponsive, ask your GP to write to the GIC formally requesting it. Keep a copy of any correspondence. I know that sounds like a lot to ask of someone who just wants their healthcare to function, but the sad reality is that navigating this system currently requires that kind of active self-management.

When you move between areas or services

Moving house is a particular risk point. Your GIC care is generally tied to the region that commissioned it. If you move to a different integrated care board area, you may effectively lose your place and need to re-refer. NHS England's specialised commissioning structure means that some gender services are commissioned nationally and others regionally, which creates inconsistency about what transfers and what does not.

Before you move, contact your GIC in writing and ask: what happens to my care if I move to a different area? Ask the same of your new GP surgery before you register. Get the answers in writing. If you are mid-treatment, ask the GIC to write a summary letter that your new GP can use to understand your history and current plan. A GP who has never seen a trans patient before, receiving a patient mid-prescription, needs that context.

Private services and the NHS interface

Many people have moved to private providers precisely because the NHS pathway is too slow or too broken to wait for. If you are with a private service, your GP may still be needed for prescribing if the private provider does not prescribe directly, or for monitoring if you want blood tests on the NHS rather than paying privately for them. The relationship between private provider recommendations and NHS GP cooperation is, again, not guaranteed.

Some GPs will take a letter from a private gender specialist and work from it, particularly if the specialist is experienced and the letter sets out a clear monitoring protocol. Others will not act on private recommendations at all. If your GP is willing to prescribe following a private consultation but uncertain about what to monitor, GenderGP can provide prescribing and monitoring support as part of its service, which removes some of that dependency on GP willingness.

What to do when the coordination fails

The honest answer is that you often have to manage the gap yourself, which is wrong and which should not be the case. But here is the practical map.

Keep copies of every letter between your GP and your GIC. Know what shared-care protocol you are on. Know your monitoring schedule. Ask explicitly for the tests you are due rather than waiting to be called. If your GP refuses to engage, put your concerns in writing to the practice manager and, if needed, to the integrated care board. If the GIC goes quiet, write to them: a formal written request is harder to ignore than a phone call that was not returned.

If the NHS pathway has genuinely failed you and you need care now rather than in two years, a private service is a legitimate route. The wait for an NHS GIC appointment does not pause while your body goes through changes you did not choose. Getting care is not giving up on the NHS: it is making a decision about your own health with the options actually available to you.

If there is a topic that you would like me to cover, just let Sammy know.

Dr Helen Webberley is a Gender Expert and advocate, and the founder of GenderGP. She writes about gender diversity, trans healthcare, and the systems that shape people's lives.