NHS gender clinics "not fit for purpose" as Levy Review exposes systematic failures

Adult NHS gender identity clinics are falling short on key measures of quality in terms of waiting times of up to 15 years and issues with safety, governance, and skill, according to a review commissioned by NHS England.

The Operational and Delivery Review of NHS Adult Gender Dysphoria Clinics, led by Dr David Levy, investigated all nine clinics that provide services for adults and found that all nine require immediate improvement and are failing on basic standards. The report, which came out on 18 December, concluded that the existing system has not lived up to normal NHS standards.

Very long waiting times and increased demand

The core issue on which this report is based is the level of waiting trans patients face when accessing services. Over 40,000 people were waiting for an initial appointment in March 2025. Without action, some clinics estimated waiting times of over 15 years for new referrals.

The review notes that long waits are not only distressing for patients accessing the services but also create safety risks, including people self-medicating hormones without clinical monitoring or turning to private providers to bypass delays within the NHS.

Lack of data and inconsistent care

The review also raised concerns around quality and safety, and found that there is no systematic reporting of patient outcomes data. It also noted that there is poor clinical audit activity, and inconsistent reporting of data in clinics, which does not allow commissioners to determine whether care is safe and effective.

Proposed reforms and their limitations

The report has 20 recommendations, including the following:

• Eliminating self-referral practices and adopting a GP-referral system
• Increasing the age for the adult clinic referral from 17 to 18 years
• Discharging patients awaiting surgery back to the care of the GP quicker

It also makes recommendations around the prescribing of hormones. According to the proposal in the report, the gender clinics will handle prescribing for a period of one year, after which the patients will be referred to the regional primary care hormone services run by specialist GPs.

A cautionary reset

In contrast to the Cass Review, which called for an immediate overhaul in policy, the Levy Review is largely interpreted as being about small-scale improvements. The review only services to confirm long-held truths told by patients and advocates in the treatment of trans people – that the healthcare services are overstretched and failing the patients they are meant to serve.