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This toolkit offers helpful information and resources on adult (18+) trans+ care pathways in England, reviewed by Russell-Cooke LLP.
It is intended for general information only and should not be relied upon as legal or medical advice.
Content last reviewed: 20 October 2025
A Shared Care Agreement (SCA) for gender-affirming healthcare is where a GP takes on the responsibility for prescribing and monitoring medications for a patient who is being treated by a private specialist.
This approach reduces costs for the patient while ensuring they have the necessary expertise in place.
Each party involved in the shared care arrangement has their own distinct roles and responsibilities.
How it typically works
The specialist gender clinic (whether the NHS or a private provider) initiates and monitors your treatment initially.
Once your treatment is established and stable, they may propose a shared care agreement with your GP. Under this arrangement, your GP would typically:
The specialist clinic retains responsibility for:
You may have opted for care with a private healthcare provider to help you access hormone replacement therapy while you wait for specialist care at a Gender Dysphoria Clinic (GDC) in the UK, or you may have been prescribed care through an NHS GDC.
The NHS Constitution says patients have a legal right to start specialist treatment within 18 weeks. But no UK GDC meets this standard; waiting times are measured in years, not weeks, and often exceed five years for a first appointment.
There are reports of waiting times exceeding several decades in some cases.
You can find a list of GDC services, wait times, and referral criteria from Trans Actual here.
A key first step is to organise a consultation with your GP to discuss whether they would be willing to enter into a shared care agreement.
Preparation is key.
Your GP may not know anything about:
It is best to be ready with the answers where possible, including what you want their role to be exactly, if known.
We have included some information and documents you may want to share with your GP at the bottom of this page.
As well as guidance, you should also take along any request made by your NHS/private specialist provider which your GP can consider.
Information about the specialist advice available to your GP, such as the GMC guidance on the provision of prescriptions for patients with gender dysphoria in Primary Care.
These resources outline the guidelines for GDCs; review the ones below to inform yourself about the recommended care and how it aligns with the care provided by your specialist provider.
At the appointment, your conversation with the GP will probably cover:
Patient continuity and accessibility: Shared care could ensure you can receive ongoing treatment closer to home rather than travelling long distances for routine monitoring and prescriptions. This improves treatment adherence and reduces barriers to care.
Clinical expertise sharing: The arrangement allows GPs to benefit from the specialist knowledge of the NHS GDC/private gender identity clinic while maintaining their relationship with the patient. The clinic typically provides clear protocols, monitoring guidelines, and remains available for consultation.
Resource efficiency: If this involves an NHS service, it helps address capacity constraints at specialist clinics by distributing care responsibilities effectively.
Patient safety: Proper Shared Care Agreements include clear communication channels, defined responsibilities, and monitoring protocols that can enhance patient safety compared to fragmented care or patients going without treatment. Routine monitoring and prescribing can be handled locally while complex decisions remain with specialists.
Professional development: GPs gain experience and knowledge in an area of medicine that’s increasingly important as more patients seek gender-affirming care.
You can expect your GP to then ask you questions; however, you do not have to answer if they make you uncomfortable or cause distress. Everything you say to your GP is confidential.
There is no need for your GP to examine you physically or refer you to mental health services unless you have asked for help with your mental health. Gender dysphoria is not a mental health condition, and suggesting that it is can be harmful and discriminatory.
Your GP may advise you that they are not allowed to support and prescribe you with gender affirming care. However, they have a responsibility to keep their knowledge up to date, including when it comes to trans+ healthcare. Working with a specialist service provider will allow them to upskill while only managing the aspects they are confident with.
They might also argue that gender-affirming medications are off-license, so they cannot prescribe them. This is incorrect. Medicines are prescribed off-license thousands of times across the UK every day, and off-license prescribing is legal and common in medicine when clinically justified.
The GMC’s Good Practice in Prescribing and Managing Medicines guidance supports the off-license use of medicines when it serves the patient’s best interests.
If you speak to the GP on the phone or in person, consider recording the conversation, as there will be a lot to remember. You may also have a friend accompany you to take notes.
You can inform your GP that you will be recording the call/visit if you want, for your records. They cannot use this as a justification to stop the call/visit or discharge you from their service.
You do not, however, need their permission to record. As noted by the Medical Defence Union, it’s your personal information, so GDPR doesn’t apply. Recordings (even if made secretly) can generally be used as evidence when dealing with these kinds of issues, either to show wrongdoing or to support your case.
Even with your best efforts, you may not be able to get your GP to agree to a shared care agreement.
If you are refused one, you can consider these options:
Sometimes it’s due to clinical judgement, safety concerns, interactions, or monitoring requirements.
At other times, it’s about practice policy; certain medications are only prescribed under a specialist’s care, or the practice may have a global refusal to support trans healthcare.
Ask the GP to explain their reasons clearly, in writing, with reference to any policy, guidance, rule or standard they seek to rely on.
You can also request a copy of your medical record, which should detail the GP’s reasoning.
You are entitled to request a second opinion from another GP within the practice.
Some surgeries allow you to book directly with a different GP if you’re unhappy with the first decision.
You should be clear why you disagree with the first decision.
Remember, the second GP will be able to access your medical history and records.
Specialist input often carries significant weight and can override a GP’s hesitation, with copies of any correspondence you may have.
You could ask that your GP liaise directly with the specialist to consider the appropriate approach.
Things to know:
For help and support in making a complaint, you can contact the Patients Association Helpline, which covers all of health and social care.
Seek legal advice. Many law firms have regulatory, equality law, and medical experts who can consider your set of facts and determine whether you could successfully challenge the decision.
Remember that there are deadlines you must meet if you wish to challenge a decision via a formal, legal route. You should therefore not delay seeking an initial steer on whether there is merit in pursuing a legal challenge promptly to protect yourself on a ‘limitation’ front.
Some GPs are more knowledgeable and supportive of trans healthcare. This resource from Trans Healthcare Intelligence lists trans-friendly GPs based on real patient experiences.
If you’re in a rural area with fewer local options, consider an LGBTQ-inclusive online UK GMC-registered GP service.
If you’ve completed all these steps without success, please get in touch with us at community@anne.health.
These sample letter templates have been reviewed by solicitors at Russell-Cooke LLP prior to publication. Notes on using these templates:
Subject: Request for shared care agreement with a private or NHS specialist service for gender-affirming healthcare
(Your Name)
(Your Address)
(City, Postcode)
(Your Phone Number)
(Your Email Address)
(Date)
Dr (GP’s Name)
(Practice Name)
(Practice Address)
(City, Postcode)
Dear Dr [GP’s Name],
Request for Shared Care Agreement: gender-affirming hormone therapy
I am writing to formally request that the practice enter into a shared care agreement for my gender affirming hormone replacement therapy, which has been initiated/will be initiated by [NHS Gender Identity Clinic/Private Specialist Name] under the care of [‘s GP’s Name].
Background Information
Current treatment plan
[Choose the relevant section:]
For testosterone therapy:
For oestrogen therapy:
Monitoring requirements
The specialist, [name], has recommended the following monitoring schedule: [include details, which may include information such as:]
Key parameters to monitor:
Clinical reviews: (Frequency of GP appointments for monitoring)
Supporting documentation
I have enclosed/will provide: [include all that apply to you]
Benefits of shared care
A shared care arrangement would: [Choose all those that apply and add anything further you think would be helpful]
Professional guidelines
My request aligns with:
Request
I would be grateful if you could:
I understand that you may need to discuss this with colleagues or seek additional information from the specialist service. I am happy to provide any additional documentation or attend a consultation to discuss this further.
Contact information
Should you need to contact my specialist directly: [CONTACT DETAILS]
I would welcome the opportunity to discuss this request with you at your earliest convenience. Please let me know if you require any additional information.
[Please note I consider myself to be protected by the protected characteristic of ‘gender reassignment’ under the Equality Act 2010. All my rights are reserved in this regard.]
Thank you for considering this request. I look forward to hearing from you.
Yours sincerely,
(Your signature)
(Your printed name)
Notes for adaptation:
Subject: Letter to GP requesting reconsideration of refusal to Shared Care Agreement with a private or NHS specialist service for gender-affirming healthcare
(Your Name)
(Your Address)
(City, Postal Code)
(Your Phone Number)
(Your Email Address)
Date: (Insert Date)
(GP Name)
(Practice Name)
(Practice Address)
(City, Postal Code)
Re: Request for reconsideration of Shared Care Agreement: Gender-affirming healthcare
Patient: (Your Full Name)
DOB: (Your Date of Birth)
NHS Number: (Your NHS Number)
Dear Dr. [GP Name],
I am writing to formally request reconsideration of the recent decision of [NAME] on [DATE] to decline participation in a shared care agreement (SCA) for my gender affirming healthcare with [Name of Specialist Service/Clinic].
Background
[Name of decision maker] was informed that I have been receiving specialist, gender-affirming care from [Specialist Service Name] since [Date].
My current treatment plan includes [briefly outline current treatment, e.g., hormone replacement therapy, monitoring, etc.].
The specialist, [name] has recommended a shared care arrangement to ensure continuity of care and appropriate monitoring between appointments.
Reasons for reconsideration
I respectfully ask you to reconsider your decision based on the following points:
[Choose those that apply to you]
Clinical necessity: A shared care arrangement is essential for me to have access to safe and effective gender-affirming treatment.
Professional guidelines: The General Medical Council’s guidance on treating transgender patients emphasises the importance of collaborative care. The British Medical Association and Royal College of General Practitioners have both published guidance supporting GP involvement in transgender healthcare where clinically appropriate.
NHS England policy: NHS England’s service specifications for gender dysphoria services explicitly support shared care arrangements between specialist services and primary care. This is considered standard practice for ensuring comprehensive patient care.
Patient safety: Refusing shared care may compromise my health and safety by creating gaps in monitoring and continuity of care. This could potentially expose me to unnecessary clinical risks.
Addressing potential concerns
If you continue to maintain that you will not provide shared care, please respond clearly to state the reasons for this position.
Supporting information
I have attached/can provide:
[Choose all those that apply]
Request for meeting
I would welcome the opportunity to discuss this matter further and address any specific concerns you may have. I am available to meet at your convenience to explore how we might work together to ensure my continued care.
Alternative solutions
If you maintain that shared care remains unsuitable for your practice, I would be grateful if you could:
Gender affirming healthcare is recognised as medically necessary treatment. I want to work together to ensure I receive safe, appropriate, and continuous care. A shared care arrangement serves both my clinical needs and represents good collaborative practice.
I look forward to your response within a reasonable timeframe [e.g., 2-3 weeks] and hope we can resolve this matter constructively.
[Please note I consider myself to be protected by the protected characteristic of ‘gender reassignment’ under the Equality Act 2010. All my rights are reserved in this regard.]
Thank you for your time and consideration.
Yours sincerely,
(Your Signature)
(Your Printed Name)
Attachments:
Note: Keep copies of all correspondence and consider sending by recorded delivery or email with read receipt for documentation purposes.
Subject: Complaint letter to GP/Practice manager regarding refusal to a shared Care Agreement for gender-affirming hormone therapy
(Your Name)
(Your Address)
(City, Postcode)
(Your Phone Number)
(Your Email Address)
Date: (Insert date)
(Practice Manager Name / GP Name)
(GP Practice Name)
(Practice Address)
(City, Postcode)
Formal complaint regarding refusal of Shared Care Agreement for gender-affirming hormone therapy
Dear (Practice Manager/Dr. Name),
I am writing to formally complain about [your/ your practice’s decision to refuse ] to enter into a shared care agreement (SCA) for my gender-affirming hormone replacement therapy (HRT), as recommended by [Specialist Service/Consultant Name] at [Hospital/Clinic Name]. The decision date was [DATE].
Background
On [date], I was assessed by [Specialist Name/Service], who recommended that I [commence/continue] gender affirming hormone therapy. [As is their standard practice], they requested that my GP practice enter into an SCA to provide ongoing monitoring and prescription of (specific medication, e.g., testosterone/estradiol).
On [date], I contacted your practice to discuss this shared care arrangement, and on [date], I received notification that the practice has refused to participate in this shared care agreement.
Grounds for complaint
[Choose all that apply and adapt them to your specific set of facts]
1. Failure to provide appropriate medical care
2. Discrimination
This decision effectively denies me access to essential medical treatment based on my transgender status. It may constitute unlawful discrimination on the grounds of gender reassignment, which is prohibited under the Equality Act 2010.
The NHS Constitution guarantees that patients have the right to receive NHS services free from discrimination.
4. Deviation from professional standards
The British Medical Association, the GMC and the Royal College of General Practitioners have published guidance supporting GP involvement in transgender healthcare through shared care arrangements.
All three organisations support the principle that shared care for transgender patients should follow the same frameworks as shared care for any other medical condition, with appropriate specialist support and clear agreements between all parties involved.
The refusal contradicts established best practice and professional recommendations.
Impact on patient care
This refusal has resulted in:
[Choose all that apply and adapt to your set of facts, and add anything specific that illustrates the impact]
Resolution sought
I respectfully request that the practice:
1. Immediately reconsider the decision to refuse the shared care agreement
2. Provide a written explanation of the specific clinical reasons for refusal, if maintained, including:
3. [Arrange an urgent consultation with the recommended specialist service to discuss the shared care arrangement]
4. Implement a shared care agreement within a reasonable timeframe (e.g., 14 days)
Alternative solutions
If the practice maintains its position and continues to refuse to provide shared care, I would consider accepting:
Next steps
I would appreciate a written response to this complaint within [10 working days], as per NHS complaint procedures. If this matter cannot be resolved satisfactorily at the practice level, I reserve the right to escalate this complaint to:
I am hopeful that we can resolve this matter promptly and ensure appropriate continuity of my medical care. I am available to discuss this further and would welcome the opportunity to meet to resolve these concerns.
[Please note I consider myself to be protected by the protected characteristic of ‘gender reassignment’ under the Equality Act 2010. All my rights are reserved in this regard.]
Thank you for your attention to this important matter.
Yours sincerely,
(Your Signature)
(Your Printed Name)
(Date)
Enclosures:
CC:
Subject: Escalation of formal complaint to ICB following GP Refusal to provide gender-affirming hormone therapy monitoring
(Your Name)
(Your Address)
(City, Postcode)
(Your Phone Number)
(Your Email Address)
Date: (Insert Date)
To: (ICB Name)
(ICB Address)
(City, Postcode)
Escalation of formal complaint following refusal to provide essential gender-affirming hormone therapy monitoring services
Dear ICB/PALS Team,
I am writing to formally escalate a complaint regarding the refusal of my GP practice, [name of practice] to provide essential monitoring services for my prescribed gender-affirming hormone replacement therapy (HRT) via a shared care agreement.
I believe this refusal constitutes a breach of my right to appropriate healthcare and potentially endangers my health and well-being.
Background and context
Patient details:
Timeline of events:
[Choose those that apply and add any other key dates you consider necessary to set out the background clearly]
Nature of the complaint
Through its decision, my GP practice has refused to provide the following essential monitoring services for my prescribed gender-affirming hormone replacement therapy:
[Choose those that apply to you]
Grounds for complaint
1. Breach of NHS constitution and Equality Act 2010 I am concerned that the refusal to provide these services may constitute unlawful discrimination based on my characteristic gender reassignment, under the Equality Act 2010.
The NHS Constitution guarantees my right to receive healthcare services free from discrimination.
2. Clinical negligence and patient safety Hormone replacement therapy requires regular monitoring to ensure my safety. The GP’s refusal to provide this monitoring:
3. Breach of GMC professional standards The General Medical Council’s “Good Medical Practice” guidance requires doctors to:
4. Inconsistency with NHS England Guidance NHS England guidance states that GPs should provide routine monitoring for patients receiving specialist treatment, including gender-affirming care prescribed by appropriate specialists.
Personal impact
This refusal has resulted in: [Set out the impact this has had on you; for example, this may include:]
Previous attempts at resolution
Discussions with practice staff:
(Briefly summarise key conversations and their outcomes)
Resolution sought
I request that the ICB: [choose all that apply to you]
Supporting evidence
Please find attached: [choose all that apply to you]
Legal framework references
Urgency and health implications
This matter requires urgent attention as: [choose those that apply to you]
I trust that the (ICB/PALS) will investigate this matter thoroughly and take appropriate action to ensure I receive the healthcare services I am entitled to under NHS principles of universal access and equality.
I would appreciate an acknowledgement of this complaint within (5 working days) and a full response within (20 working days) as per NHS complaints procedures.
[Please note I consider myself to be protected by the protected characteristic of ‘gender reassignment’ under the Equality Act 2010. All my rights are reserved in this regard.]
Should this matter not be resolved satisfactorily, I reserve the right to escalate matters.
Thank you for your attention to this serious matter.
Yours sincerely,
(Your Signature)
(Your Printed Name)
Attachments:
Contact information for follow-up:
If you remain unhappy with how your complaint has been handled following the conclusion of local resolution, you can ask the Parliamentary and Health Service Ombudsman (PHSO) to review your complaint.
Attachments:
Contact information for follow-up:
If you remain unhappy with how your complaint has been handled following the conclusion of local resolution, you can ask the Parliamentary and Health Service Ombudsman (PHSO) to review your complaint.
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