A Health Service With Its Priorities Reversed
The NHS waiting list for elective care in England stood at approximately 7.5 million cases as of early 2025, according to NHS England's own published figures. That number represents millions of individuals — real people, with real conditions — enduring pain, anxiety, and in some cases irreversible deterioration while they wait for procedures that their clinicians have judged necessary. Hip replacements. Cataract removals. Cardiac investigations. Cancer follow-ups. The human cost of that queue is not hypothetical; it is documented in patient surveys, coroner's reports, and the quiet desperation of GPs who have run out of ways to explain the delay.
Against that backdrop, Freedom of Information requests submitted to NHS trusts in recent years have revealed a pattern of spending that is difficult to defend on any grounds that a reasonable person would recognise as clinical. Trusts have disclosed expenditure on mandatory equality, diversity and inclusion training programmes — including, specifically, training focused on gender identity and pronoun use — delivered by external consultants at day rates that would raise eyebrows in the private sector. Some trusts have established dedicated DEI teams whose function is not the delivery of healthcare but the management of ideological compliance.
The sums involved vary by trust and are not always straightforwardly extractable from published accounts, partly because DEI expenditure is frequently embedded within broader workforce or organisational development budgets rather than itemised as a discrete cost centre. This opacity is itself a problem. Taxpayers funding the NHS are entitled to know, in clear terms, how much of their money is being spent on activities that have no direct bearing on clinical outcomes.
What the FOI Disclosures Show
Investigative work by a number of journalists and transparency campaigners has brought specific examples into the public domain. Several NHS trusts have disclosed spending with external DEI consultancies running to tens of thousands of pounds per engagement. Training programmes specifically covering gender identity — including guidance on staff use of preferred pronouns, the creation of gender-neutral facilities, and the management of transgender patients' records — have been introduced as mandatory requirements in a number of trusts, meaning that clinical staff are required to complete them regardless of their relevance to the individual's professional role.
The Cass Review, published in April 2024 and representing the most comprehensive independent examination of gender identity services in the NHS's history, was notable not only for its findings on the treatment of children and young people but for what it revealed about the broader institutional culture. Dr Hilary Cass and her team documented an environment in which ideological commitment had in some instances displaced clinical rigour — where the question of what the evidence said had become secondary to the question of what the prevailing institutional orthodoxy required. That finding was not incidental to the review's conclusions; it was central to them.
Photo: Cass Review, via translucent.org.uk
Photo: Dr Hilary Cass, via www.thepinknews.com
The NHS England leadership accepted the Cass Review's findings and committed to implementing its recommendations. Whether the cultural shift required to give those commitments meaning has actually occurred within individual trusts is, at best, an open question.
The Defence — and Its Limits
The strongest version of the argument in favour of this spending runs as follows: NHS staff interact with a diverse patient population, including transgender patients who report significant difficulties accessing respectful and appropriate care. Training that helps clinical staff understand and respond sensitively to those patients' needs is not a luxury; it is a component of delivering equitable healthcare. The cost of such training is modest relative to the overall NHS budget, and the benefit — in terms of patient experience and staff confidence — is real.
This argument deserves to be engaged with honestly rather than dismissed. It is true that transgender patients, like all patients, deserve to be treated with dignity. It is true that some staff benefit from guidance on navigating complex clinical and interpersonal situations. And it is true that the sums involved in any individual training programme are small relative to the NHS's £180 billion annual budget.
But the argument has serious weaknesses that its proponents rarely acknowledge. The first is prioritisation. When a trust is simultaneously running a waiting list of tens of thousands of patients and spending money on mandatory ideological training for staff with no relevant patient-facing role, the question of whether that money could not be better directed elsewhere is not hostile; it is basic governance. The second weakness is compulsion. Training that is genuinely about clinical competence does not need to be mandatory for all staff regardless of role; the decision to make it so reflects an institutional choice to enforce ideological conformity rather than to develop specific clinical skills. The third is the involvement of external consultants — a category of expenditure that, across the public sector, has a long and well-documented history of delivering poor value for money.
The Accountability Gap
NHS trust boards are legally required to demonstrate value for money in their spending decisions. They are required to publish annual accounts and to subject themselves to audit. In practice, however, the scrutiny applied to workforce and organisational development expenditure is far lighter than that applied to, say, procurement of medical equipment or pharmaceutical contracts. DEI spending — precisely because it is politically contentious to challenge — tends to escape the rigorous cost-benefit analysis that any other category of expenditure would face.
This accountability gap is not accidental. It is the product of an institutional culture in which challenging DEI spending is perceived — and in some cases explicitly treated — as evidence of prejudice rather than as legitimate financial scrutiny. Senior clinicians who have raised questions about the relevance or proportionality of mandatory gender identity training have, in documented cases, found themselves subject to the same institutional pressure that characterises the broader whistleblower problem. The culture of ideological conformity and the culture of institutional self-preservation are, in this respect, mutually reinforcing.
What a Conservative Health Policy Looks Like
The conservative case here is not complicated, and it does not require hostility to any patient group. A health service funded by general taxation has a primary obligation to deliver clinical care to the people who need it. Every pound spent on activities that do not contribute to that obligation is a pound not spent on reducing the waiting list, training an additional nurse, or purchasing a piece of diagnostic equipment. The test for any item of NHS expenditure should be simple: does this improve patient outcomes? If the honest answer is no — or even not demonstrably — then the expenditure requires justification of a kind that most DEI programmes cannot currently provide.
A future Conservative government serious about NHS reform should legislate to require trusts to itemise DEI expenditure separately in their published accounts, to demonstrate the clinical rationale for mandatory training programmes, and to subject external consultancy contracts in this area to the same competitive tendering requirements that apply elsewhere. Sunlight, as the saying goes, is the best disinfectant.
The NHS is a national institution of genuine importance, funded by the labour of every working person in Britain. It deserves leadership that treats clinical outcomes as the only metric that matters — not leadership that mistakes ideological compliance for organisational progress while patients wait in pain.
A health service that prioritises pronoun training over patient care has not lost its way by accident — it has been led there by people who should be held to account.
