NHS Children and Young People’s Gender Service Specification

Overview

This consultation asks for your views on proposed changes to the service specification for specialist gender incongruence services for children and young people, which will describe how current and future providers of NHS Children and Young People’s Gender Services will deliver the service.

This revised version follows publication of an interim service specification in June 2023,which was developed in response to the interim advice of the independent review of NHS gender identity services for children and young people (the Cass Review).

The interim service specification described a more cautious and holistic approach to diagnosing and caring for children and young people presenting with gender incongruence in line with the interim recommendations of the Cass Review. NHS England held a public consultation on the interim specification in 2022. The consultation received 5,183 responses and NHS England’s response can be found on the NHS England website.

Respondents to the previous consultation were informed that NHS England would review, and possibly update, the interim service specification once the Cass Review had delivered final advice and recommendations.

This document describes the changes that we are now proposing, with the purpose of aligning the specification with the final report of the Cass Review (April 2024).

This draft service specification was tested with registered stakeholders between 7 and 25 April 2025. The process of stakeholder testing demonstrated that there remains a divergence of views amongst stakeholders on the content of the proposed service specification, and broader issues related to the clinical approach for children and young people who present with gender incongruence. Having carefully considered the submissions, NHS England has decided to proceed to public consultation with minor amendments to the version of the service specification that went out to stakeholder testing in April 2025:

• a proposal for a separate pathway for pre-pubertal children;
• the inclusion of proposed provider-reported metrics; and
• a description of arrangements for data collection, audit and evaluation.

The proposals have been developed in consultation with the Clinical Reference Group for Children and Young People’s Gender Services.

The deadline for submitting your responses is 2 November 2025.

Proposed changes to the service specification

NHS England has updated the service specification to reflect the findings and recommendations of the final Cass Report. Having carefully considered the Cass Review’s final advice, the changes proposed maintain and build on the holistic and cautious approach described in the interim service specification.

The final service specification proposes some limited revisions which aim to reflect the fundamentally different approach to the assessment, diagnosis and treatment of children and young people presenting with gender incongruence that the Cass Review described.

The changes also align the service specification with the updated clinical commissioning policies for Puberty Suppressing Hormones and exogenous hormones published by NHS England in March 2024, and with the separate service specification published in August 2024 that describes the referral pathway for children and young people presenting with gender incongruence.

The service specification has been amended as follows: 

1. The service specification details a holistic assessment framework. The previous description of the clinical model has been replaced with a description of the holistic assessment framework from the final Cass Report, alongside the Cass Report’s description of the process of diagnosis, formulation and individualised care planning. This change builds on the holistic approach established in the interim specification and provides greater clarity on the approach to clinical assessment and process of diagnostic formulation.
2. The description of the role and function of the National Provider Network. This change supports NHS England’s intention, set out in its plan for implementing the Cass Review, to support the new specialist gender services by forming a National Provider Network. The National Provider Network will ensure that there is a consistent approach to various elements of service delivery, including research, data collection, clinical audit, training and education of staff, and the management of the National Multidisciplinary Team that reviews clinical recommendations for hormone intervention.
3. Arrangements for data collection, audit and evaluation. This includes a description of a coordinated, single data registry to support service evaluation and quality improvement.
4. The role of the Children and Young People’s Gender Service in leading a network of Designated Local Specialist Services. The revisions align the specification with the final report of the Cass Review, which recommends that NHS England and service providers should establish regional networks of local services that include primary care, mental health services and paediatric services. The changes will support greater integration of the specialist gender services with other local services to support all of a child or young person’s clinical needs.
5. The inclusion of endocrinology as a core function within the Children and Young People’s Gender Service’s Multi-disciplinary Team.  The final Cass Report recommended that the Children and Young People’s Gender Services must have the ability to provide essential related services to support the broad range of presentations this group of children and young people may have or be able to access such services through provider collaborations, including “access to endocrinology services for those seeking medical intervention”.
6. Alignment of the service specification with the ancillary service specification Referral Pathway for Specialist Service for Children and Young People with Gender Incongruence (August 2024). The revised service specification links to the published service specification that describes access arrangements to the national waiting list from 1 September 2024. That is: all new referrals to NHS Children and Young People’s Gender Services must be made through NHS secondary care services (mental health or paediatric services) to ensure that every child or young person has a thorough assessment of need, and that those who need it receive appropriate support from local NHS services while they remain on the waiting list.
7. Alignment of the service specification with NHS England’s clinical commissioning policy for Puberty Suppressing Hormones and with NHS England’s clinical commissioning policy for Gender Affirming Hormones (March 2024) - and with recent government legislation that places restrictions on private prescribing. The interim service specification clarified NHS England’s position in relation to children and young people who source prescriptions or medicines from unregulated sources or providers, including online providers that are not regulated by UK regulatory bodies. The specification ‘strongly discourages’ children, young people, and their families, from sourcing medicines outside of NHS protocols. The revised specification further clarifies this position, including a description that the NHS Children and Young People’s Gender Service will not assume responsibility for the prescribing or monitoring of any medication initiated outside of the service.
8. The addition of provider-reported metrics. The revised service specification includes proposed metrics to support commissioners to monitor and assess the quality of the service. Additional metrics will be developed over time, including those that seek to measure clinical outcomes.

9. A separate pathway for pre-pubertal children. Being mindful of the advice of the Cass Review that the current evidence base suggests that children who present with gender incongruence at a young age are most likely to desist before puberty, a separate pathway will be established for pre-pubertal children and their families so that these children and their families are seen for early discussion

What is NHS England asking you to do?

We are inviting you to review this consultation document and the revised draft service specification, and to share your views on our proposals. Your input is critical to the development of effective and meaningful national standards. You may also wish to read the equality and health inequalities assessment (EHIA). The EHIA considers submissions in relation to the equalities and health inequalities impact of the proposed changes provided by stakeholders during the early engagement process.

You are welcome to respond on behalf of your group or organisation, or as an individual. You may wish to consult others as part of your response, or to provide a group response to the consultation.

You must declare any conflict of interests relating to this document or service area. Please do not provide any personal or clinical information about yourself, as this will be deleted and cannot be included in the consultation report.

All questions (see Appendix below) are optional, and you can review them before you start.
The consultation is open for 90 days between 4 August and 2 November 2025. Please submit your response by 2 November 2025.

If you are experiencing any difficulties in accessing the consultation documents, or if you have any questions about this consultation, please email england.scengagement@nhs.net.

What happens after NHS England receives responses?

NHS England will review all the feedback that is submitted and consider any potential revisions to the proposed specification. NHS England will also commission an independent third party to undertake an independent analysis of the consultation responses and to a produce a written report of the findings. All contributions will be anonymised.

Once a revised specification is agreed, it will be published on the NHS England website alongside the independent consultation report.  

Related documents

The updated service specification aligns with the Cass Review recommendations, clinical policies and referral pathway. We are not seeking feedback on these publications, but you may wish to read them in considering your response.

• NHS England’s clinical commissioning policy for Puberty Suppressing Hormones (March 2024) 
• NHS England’s clinical commissioning policy for Gender Affirming Hormones (March 2024) 
• Referral Pathway for Specialist Service for Children and Young People with Gender Incongruence (August 2024) 
• Independent analysis of consultation submissions to the 2023 service specification 
• Final report of the Cass Review 
• NHS England’s plan for implementing the Cass Review final report

Appendix: consultation questions

The consultation asks the following questions:  

1. In what capacity are you responding?
(Patient / Parent / Clinician / Service Provider / Other; If you have selected ‘Other’, please specify)

2. Are you responding on behalf of an organisation?
(Yes / No; If you have selected ‘Yes’, which organisation are you responding on behalf of?)

3. To what extent do you support the inclusion of the holistic assessment of needs (Appendix A in the service specification)?
(Agree / Partially Agree / Neither Agree nor Disagree / Partially Disagree / Disagree; Comments (in under 500 words))

4. To what extent do you agree with the approach to the management of patients accessing prescriptions from un-regulated sources as explained above?
(Agree / Partially Agree / Neither Agree nor Disagree / Partially Disagree / Disagree; Comments (in under 500 words))

5. To what extent do you support the following other proposed changes to the specification as described above:

a. The description of the role and function of the National Provider Network.  
(Agree / Partially Agree / Neither Agree nor Disagree / Partially Disagree / Disagree; Comments (in under 500 words))

b. The description of the arrangements for data collection, audit and evaluation.
(Agree / Partially Agree / Neither Agree nor Disagree / Partially Disagree / Disagree; Comments (in under 500 words))

c. The role of the Children and Young People’s Gender Service in leading a network of Designated Local Specialist Services.  
(Agree / Partially Agree / Neither Agree nor Disagree / Partially Disagree / Disagree; Comments (in under 500 words))

d. The inclusion of endocrinology as a core function within the Children and Young People’s Gender Service’s Multi-disciplinary Team.
(Agree / Partially Agree / Neither Agree nor Disagree / Partially Disagree / Disagree; Comments (in under 500 words))

e. The separate pathway for pre-pubertal children. (Agree / Partially Agree / Neither Agree nor Disagree / Partially Disagree / Disagree; Comments (in under 500 words)

6. The proposed provider-reported metrics aim to help monitor and assess the quality of the service. To what extent do you agree with the inclusion of the metrics?
(Agree / Partially Agree / Neither Agree nor Disagree / Partially Disagree / Disagree; Comments (in under 500 words))

7. Are there any other changes or additions to the revised service specification that should be considered?
(Yes / No; If you have selected ‘Yes’, please explain)

8. To what extent do you agree that the Equality and Health Inequalities Impact assessment reflects the potential impact on equalities or health inequalities which could arise because of the proposed changes?
(Agree / Partially Agree / Neither Agree nor Disagree / Partially Disagree / Disagree; Comments (in under 500 words))