The reception and admin area of Charing Cross Gender Identity Clinic, swamped with work, as usual.

That the administrative side of Charing Cross GIC is reputed to be obscenely slow is no secret. In fact, given the experiences of some patients, a GP (Family Doctor for the Americans reading this) might be excused for wondering if the clinicians at the GIC are required to type up their letters themselves.

In realising the importance of this issue, however, last month we sent a pair of Freedom of Information requests to the trust, and the results have just arrived. The information returned provides an insight as to the provision for admin services,  and the process of sending those all important letters to a patient’s GP, delays which can lead to immense patient distress as well as other medical delays.

Though the current turnaround on letters sent to patient’s GPs is stated to be around 6 weeks, it is not unheard of for this to actually take in excess of two months. This long-standing issue has varied in impact upon patient welfare and treatment, and has at times resulted in horrific delays of as much as a quarter of a year before patients have been able to get their medication regime changed by their GP, even having been told of the urgency of such a change at their GIC appointment.

The admin provision at CHX GIC comprises of an Office Manager, 2 Receptionists, a “New Patient Administrator”, a Medical Records Administrator, and 3 Administrators/typists, all of whom work on a full time basis. No information has been given as to the definition of “full time”, but in the UK this can be defined as a role of more than 16 hours per week, or the more commonly accepted 37.5 hours per week. This covers an average of 95 patients per week, each of whom has a letter concerning them written to their GP, which can be up to 3 pages long.

The administrative posts are expected to spend up to two thirds of their time typing, but this cannot be guaranteed as they regularly become caught up in other duties such as filing, approximately 80 telephone queries per day, reception duties, perhaps a little disturbingly “dealing with patients whose details have been deleted as a consequence of the
Gender Recognition Act”, arranging appointments, etc.

Even so, assuming that an administrator is able to type for the expected two thirds of their time, this leads to 75 hours per week dedicated to typing up 95 dictated letters of up to 3 pages long. However, this does not account for the fact that a single patient contact frequently generates as many as 4 letters dictated by a clinician regarding a wide range of subjects including funding issues and disputes, letters sent to other specialists involved in the care of the patient, letters written in support of passport applications and advice  to GPs on blood results and hormone management, which are written routinely.

Though all these letters are generally dictated by the clinician within 48 hours and passed over to the typing pool, no account, as yet, is taken of instances where delays may ensue due to waiting for blood results or other opinions, sickness and other absences.

It can be said, therefore, that where a typist has not been caught up in other numerous and ever-present duties in the administration of the GIC, he or she has on average 48 minutes to type a dictated letter of three pages long, assuming that each patient contact has generated only one letter. Having said that; in assuming a reasonably conservative estimate from the information given, that a third of patients generate four letters and the remaining two thirds generate only one, this time would reduce to a rate of 24 minutes per letter typed. A professional touch typist, typing at a rate of 60 words per minute without interruption, would type a standard page in around 5 minutes. “Hunt and peck” typists peak at approximately 27 words per minute, or a full page every 10 minutes. Most of the rest of us are slower still.

After the letters are typed up, they are each “returned to the clinician for checking, amendments and/or their signature”, before being sent out by post to the GP or other specialist.

The NHS trust responsible for the clinic states that the current turnaround between a patient attending an appointment and a letter being sent to a patient’s GP or other specialist is, on average, around 6 weeks. The trust aims for this turnaround to be 2 weeks, and as such, “an admin review has been commissioned with this having been identified as an objective” in an attempt to rectify this years-old problem. It is not the first time the trust has ‘attempted’ to rectify this problem for which 6 weeks will, to many people, look like a gross underestimate. It is stated that a letter resulting from the clinic’s endocrinologist typically turns around in approximately 2 weeks, or communication will be made straight away if the information is deemed to be urgent.

In mitigation for these delays, they state that “there is however a system in place to ensure that priority letters are dealt with appropriately”. This consists of the typist prioritising those letters dictated by a non-endocrinologist clinician, where the clinician has deemed the letter to be urgent. Some clinicians nevertheless hand write a letter to the patient’s GP on the day in respect of initiation or amendment of a patient’s hormone therapy regime.

Back in the real world for a moment, however, it becomes reasonably clear where the admin delays at CHX GIC stem from. In the real world, people are not robots; not even employees in admin roles. Things don’t happen one at a time, or in order. Often, things don’t even follow the plan. The role of an administrator is not to perform theoretical functions, but to perform these functions within a reality that is constantly changing, and to still some how get everything done such that things keep running. It is then, no wonder that there are such delays on the admin side of CHX GIC.

When the numbers are broken down, it almost looks as though someone has performed a time and motion study, added in a few minutes of extra time to account for a little variance, and declared that all is then well. Real life is not like that, and the admin staff, from the information given, would appear to be over-worked, and working under significant pressure.

Of course, this has all been about the outbound mail of the GIC. It nevertheless says a lot from which a possible scenario of an inbound contact might proceed. A letter requiring the attention of a clinician is sent in, say, November, but the backlog of work and the volume of ongoing work mean that it’s a little time before the letter is both passed into records and acknowledged.

From that point comes a significant wait until such time as the clinician(s) concerned have the time to read and act upon that letter; perhaps it may require discussion with another clinician or two, or worse, could require the input of a non-GIC specialist to whom another letter must be written and a reply received before acting on it once more. A letter is then dictated within 48 hours, which must enter the typing pool to be presented to the clinician some weeks or months later for approval. Only then is a reply sent, potentially some quarter or half a year or more later.

The cost of a CHX GIC appointment charged to a PCT in 2007 was £561 for first, second, and “other” appointments, and  £297 for follow-up sessions, as discovered by Sarah Brown (AKA, Aunty Sarah). The price of seeing Dr Perring for any such appointment in 2011 is £250… still a full £47 cheaper than the price charged for CHX’s follow-up appointments 5 years ago! Perhaps then, West London Mental Health Trust might consider the additional subsidy other PCT’s are effectively paying them for the services of this internationally-renowned “centre of excellence” (as CHX likes to be known) as a good source of funding for the employment of a full time professional touch typist befitting of such a title. It’d cost around £20,000 per annum to employ such a touch typist, which would surely be money well spent, and easily afforded from the artificially inflated charge for their services.

Not only would this additional 45 pages per day (assuming a typing speed of half the professional typing rate of 60 words per minute) make a significant dent in the backlog, but it’d help ensure that both services and admin run smoothly, and patients aren’t needlessly distressed and kept waiting for, frankly, abhorrent periods of time. That should help to meet the two week turnaround target easily.

On the other hand, perhaps the NHS might consider adopting email as a method of communication along with the rest of the 21st century. That way, clinicians could even type their own letters as many may already suspect of them given the time it takes for them to be sent. In fact, with some clinicians already realising the need to handwrite letters to patients’ GPs, such a change may even save money as well as improve efficiency!

The freedom of information requests and the responses received can be found both here, and here.

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