Primary Care, Psychiatry and Public Health ICU



Primary Care, Psychiatry and Public Health ICU

Student Selected Component:

An Audit Of Outpatient Non-Attendance

At The Leeds Gender Identity Disorder Service

Nadeem Akhtar, Ian Anderson, Victoria Brown,

Charlotte Davies & Samina Koser

Abstract:

Background: Where incongruity exists between one’s anatomical sex and gender identity, anxiety and persistent feelings of discomfort with their sex that result are recognised clinically as gender dysphoria and these people may require gender reassignment surgery.

Introduction: Annually, 12% of clinic appointments are missed, costing The National Health Service (NHS) in excess of £300 million per anum as well as wasting considerable resources (both human and otherwise). Clinical staff at Leeds Gender Identity Disorder Service (GIDS) suspect a high level of non-attendance at their clinics but have never previously monitored this. Leeds GIDS have set a benchmark for “acceptability” as non-attendance rates equal to or lower than the average for the rest of Leeds Mental Health Trust (i.e.19.8%).

Methods: An audit tool was designed to assess the DNA (did not attend) rates and possible causal factors for non-attendance. The data collected was assessed to determine the attendance rate and the demographic data from the “DNA” and “Attended” cohorts was compared to suggest which patient factors might be most influential in determining attendance.

Results: For the year studied Leeds GIDS had a DNA rate of 30%. The factors most strongly linked with non-attendance were increasing distance travelled to clinic, early morning appointments and lower social classes.

Discussion: Suggestions on how to improve the DNA rate have been made- these include a change of protocol to remove passive ‘DNAs’, more patient choice for appointment time, re-written letters and improved methods of contacting the clinic.

Conclusion: Leeds GIDS has a poor attendance record, as defined by their own benchmark and the specified changes need to be implemented before the audit cycle can be completed to assess their efficacy.

Background:

It is a common misconception, in modern society, to view someone’s (biological) sex and their (self-perceived) gender identity as synonymous. It follows therefore, that complications may follow when the naïve use someone’s anatomical sex to make assumptions about their gender identity (their sense of masculinity or femininity) and gender role (their outward appearance and behaviour). It is important to remember that an individual’s sexuality (to whom they find themselves physically attracted) is a completely separate matter again, although further assumptions made about this can cause further issues. It is relatively common for individuals to maintain a gender role that is in keeping with their sex, despite readily identifying with a contrasting sense of gender identity (see below).

|Gender Role |

| | |‘…behaviours, attitudes and personality traits that a society, in a given culture and historical period, |

| | |designates as masculine or feminine, that are more “appropriate” or typical for the male or female social |

| | |role. In young children the measurement of gender role behaviour includes several easily observable phenomena,|

| | |including affiliative preference for same sex vs opposite sex peers, interest in rough and tumble play, |

| | |fantasy roles, toy interests and dress-up play.’ |

|Reproduced From: |

|Bailey and Zucker. Childhood sex typed behaviour and sexual orientation: a conceptual |

|analysis and quantitative review. Developmental Psychology 1995; 31: 43-55 |

While individuals with incongruity between their anatomical sex and gender identity are not medically unwell, the resulting anxiety and persistent feelings of discomfort with their anatomical sex that these individuals usually experience from childhood onwards are recognised clinically as gender dysphoria or transsexualism. Transsexuals have strong, ongoing, cross-gender identification with a desire to live and be accepted as a member of the opposite sex.1 The World Health Organisation recognises transsexualism in its International Statistical Classification of Diseases and Related Health Problems (ICD-10) as follows: 2

|Gender identity disorders |

|F64.0 | |Transsexualism |

| | |A desire to live and be accepted as a member of the opposite sex, usually accompanied by a sense of discomfort|

| | |with, or inappropriateness of, one's anatomic sex, and a wish to have surgery and hormonal treatment to make |

| | |one's body as congruent as possible with one's preferred sex. |

In the United Kingdom, it is estimated that approximately one in 30,000 genetically male adults and one in 100,000 genetically female adults wish to change their sex, although a more recent study in the Netherlands suggests that these figures may now be nearer to one in 11,900 and one in 30,400 respectively.3,4 The aetiology of gender dysphoria is debatable; some people believe that it is a product of the nurturing aspects of gender reinforcements and programming, while others believe it to be a reflection of maternal mental health during pregnancy.1 Many popular hypotheses acknowledge that gender identity is determined, at least in part, by circulating hormone levels during one’s foetal development and the effects that these have on the brain.5 There is evidence to suggest that gender identity becomes fixed in early childhood.6 It is most likely that determination of gender is actually multifactorial and that it would therefore be better suited to a sliding scale of masculinity/femininity than being “shoe-horned” into a dichotomy so that it is in keeping with the biological sexes.

If a patient presents with suspected gender dysphoria, a medical practitioner should diagnose this if they are able to elicit clinically significant long-term anxiety, distress and impairment in social and occupational functioning, in the absence of a genetic abnormality.3 Patients diagnosed with gender dysphoria are referred to a specialist gender dysphoria clinic, usually by a psychiatrist. As alternatives to sex reassignment surgery, gender dysphoria clinics are able to offer a number of adjuvants to aid people to live their lives while maintaining their physiological sex. These services may include counselling, speech therapy, electrolysis (to remove facial hair) or hormone treatments. Some more minor cosmetic procedures are also available that will not affect one’s fertility, such as a thyroid chondroplasty (shaving of the Adam’s apple) or breast implants.7

If sex reassignment surgery is decided upon, the person must have lived in role for a minimum of one year before surgery is started. A biological male wishing to become female will be given female hormones; in order to produce changes in the secondary sex characteristics (such as body hair reduction and breast development) electrolysis may also be offered. During the operation, an artificial vagina is created and lined with skin from the penis and the scrotum is used to fashion a labia, and the urethra shortened and repositioned. For the female to male patient, male hormones are given, increasing hair growth (especially of facial hair) masculine muscle development, and deepening of the voice. A mastectomy is performed and the ovaries and uterus also removed. Penis construction, artificial testicular implants and urethral repositioning are available but the surgery is complex.3 For both groups, hormone treatment should have been commenced at least one year prior to surgery to allow the body’s levels to stabilise.

Introduction:

The costs incurred by the National Health Service (NHS) when patients do not attend (DNA) outpatient appointments are high, both financially and otherwise. In 1984, a paper written to assess the impact of missed appointments found that of the 35.5 million NHS appointments to outpatients that are made annually, five million (14%) were missed, at an estimated financial cost of £266 million.8 By the turn of the century, the annual cost had already risen to well in excess of £300 million and was showing no signs of slowing.9, 10 On an individual level, the average missed appointment is estimated to cost the NHS £65, with lengthier appointments costing significantly more.11 In addition to the frustration that staff experience when patients are absent from clinic without warning, other resources such as clinic rooms and medical equipment are also booked up when they might have been used elsewhere. The effects of non-attendance are not even confined to the NHS and its employees; they significantly contribute to patient waiting lists, thereby inconveniencing other people who are waiting to be seen as quickly as is possible. One study concluded that outpatient non-attendance might increase waiting lists by anything from one week to six months.12

Nationally, the DNA rate stands at 12%, although this can vary from speciality to speciality and from region to region. Studies have reported DNA rates ranging from five to 34%.13, 14 DNA rates are generally elevated in psychiatric subspecialties and departments and this is not surprising, given that the main reasons for patient non-attendance include forgetting the appointment, illness, work commitments and difficulties with transportation; problems that are particularly prevalent among the psychiatric patient contingent.10 In addition to the aforementioned reasons that patients commonly use to explain their absence from clinic, there are certain demographical factors that seem to be associated with non-attendance. One prospective study illustrated the main patient demographics associated with hospital non-attendance are: male sex, youth, social deprivation and being unemployed. This study also found that non-attendees were less likely to own a car or a telephone.15 The impact of non-attendance at psychiatric outpatient clinics is compounded by the length of appointments that patients are offered. In psychiatry, it is not uncommon for patients to be offered appointments that are an hour or even 90 minutes in duration and if one of these appointments is missed, it wastes a great deal of clinicians’ time and resources. Furthermore, non-attendance may actually be an indicator of the severity of the illness in psychiatric patients.16

A study by Lacy et al. found that, where patients DNA clinics, there was often a previous history of non-attendance.17 This paper also concluded that non-attendees were less likely to have understood the reason for and nature of their appointment in the first place. As well as confirming that patients’ reasons for not attending were commonly centred on forgetfulness, trouble missing work, arranging childcare and transportation, this paper also found a significant correlation between non-attendance and increasing length of time between appointment scheduling and the appointment itself. It is supposed that longer waiting times lead to less reliable appointment keeping, through loss of trust and satisfaction. In their paper, Ritchie et al. described how, in psychiatry there is particular concern that non-attendance can represent deterioration in the mental health and thus may indicate risk of harm to the patient or to others if ignored.18

From discussion with clinical staff at the Leeds Gender Identity Disorder Service (Leeds GIDS), the perceived DNA rate for their outpatient clinics is very high. Having said this, the team at Leeds GIDS has never previously audited its DNA rates and there are currently no defined protocols in place to ensure good attendance. The Leeds GIDS have therefore defined the benchmark for “acceptability” as having outpatient attendance rates equal to the average for the Leeds Mental Health Trust, indeed they eventually aim to be one of the best performing departments within the trust. It is hoped that by investigating the current DNA rates and exploring potential causal factors for non-attendance, it will be possible to suggest changes that can then be implemented and subsequently re-audited to evaluate their efficacy.

Under the terms of the Freedom of Information Act 2000, Leeds Mental Health Trust must make its records of attendance rates publicly available. In 2004, The Healthcare Commission have compared the rates of missed outpatient appointments across all of the Nation’s Mental Health Trusts and have banded the trusts according to these (see table below).19 The bands range from Band one (poorest) to Band five (best) and Leeds Mental Health Trust gained Band three status.

|Healthcare Commission’s Missed Outpatient Appointment Rate Banding: |

|Poor |Band One |Greater than 27.4% |

| |Band Two |Less than or equal to 27.4% and greater than 20.9% |

| |Band Three |Less than or equal to 20.9% and greater than 15.0% |

| |Band Four |Less than or equal to 15.0% and greater than 11.3% |

|Good |Band Five |Less than or equal to 11.3% |

Within the Leeds Mental Health Trust, the DNA rate varies markedly between the specialties. Over the three-year period from 2003-4 until 2005-6, the best performing speciality was psychotherapy, which enjoyed a mean DNA rate of 7.1%, whereas the worst performing speciality (liaison psychiatry) had a mean DNA rate of 26.0%. Over the same period, the Leeds Mental Health Trust’s overall DNA rate was 19.8%. A summary of the year-by-year results can be seen below:

|A Comparison Of Outpatient Appointment Rates Within Leeds Mental Health Trust: |

|Year |Highest DNA Rate |Lowest DNA Rate |Overall Trust DNA Rate|

|2003-4 |Forensic Services (25.6%) |Psychotherapy (5.7%) |20.8% |

|2004-5 |Liaison Psychiatry (26.3%) |Eating Disorders (2.0%) |20.8% |

|2005-6 |Liaison Psychiatry (28.9%) |Eating Disorders (4.4%) |18.1% |

|3-Year Period |Liaison Psychiatry (26.0%) |Psychotherapy (7.1%) |19.8% |

Leeds GIDS defined the benchmark for “acceptability” as having outpatient attendance rates equal to the average for the Leeds Mental Health Trust, this can now be quantified; 19.8%. Similarly, the ideal standard that the Leeds GIDS hopes to eventually achieve is a non-attendance rate at least as low as 7.1%.

Objectives:

• Audit the DNA rates for first appointments at clinics in the Leeds GIDS against the average DNA rate in the Leeds Mental Health Trust.

• Use the data collected in order to ascertain possible reasons why patients may not attend their appointments.

• Feedback the results and provide recommendations for change to improve attendance to the Leeds GIDS that may be implemented and audited again at a later date.

Methods:

Project Plan:

|Task |Timing |

|Background Research- about DNA rates, conducting an audit, what is gender dysphoria? |Weeks 1-4 |

|Design Audit tool |Week 1 |

|Pilot Study- conduct pilot, and make necessary changes |Week 5 |

|Data Collection |Week 6 |

|Data Analysis |Weeks 6-7 |

|Discussion- including recommendations for future practice |Weeks 7-8 |

|Writing Report |Weeks 6-10 |

Background:

In order to review the existing literature surrounding gender dysphoria and DNAs, a search was performed using the Medline database. The search was limited to publications between 1966 and May, week three, 2006, and to articles written in English. The search terms used and combined were: DNA, did not attend, non-attendance, psychiatry, out-patient and mental health. The terms gender dysphoria, gender identity, transsexual, transsexualism and sex change were used to obtain background information on the subject. A combined search for the gender dysphoria and non-attendance terms yielded no results. The searches were repeated using the Internet search engine Google.20

Under the terms of the Freedom of Information Act 2000, Leeds Mental Health Trust must make its records of attendance rates publicly available. These were obtained following a written request to Leeds Mental Health Trust Headquarters.

Audit Tool (Appendix one):

An initial inquiry tool was produced, which did not only include information about the assessment appointment in but also some general patient demographics that could then be analysed to ascertain possible reasons for any DNA. The tool was produced using Microsoft Excel so formulas could be used that meant the program would calculate things such as age from the date of birth and distance from the postcode. The headings were:

• Patient ID-in order to keep track of notes that had been audited. This information was not for use in the analysis.

• Date of Birth

• Postcode- to be used to calculate the distance the patient has to travel to the clinic

• Starting Sex- before commencing treatment

• Deed pole- was there evidence of the patient changing their name by deed pole in the medical notes?

• Social Class-

o I- Professional occupations

o II- Managerial and Technical occupations

o III- Skilled occupations

o IV- Partly-skilled occupations

o V- Unskilled occupations

o VI- Student

o VII- Unemployed

• Is the patient living with a partner?

• Number of Children

• Any previous referral to mental health service unrelated to gender identity disorder

• Each appointment (1st, 2nd, 3rd etc…)

o Month and year

o Time of day- rounded to nearest hour

o Attended?- yes/no/cancelled

• Date of referral to service- in order to calculate waiting time for 1st appointment

Pilot Study:

A pilot study was conducted using the initial audit tool to ascertain its effectiveness and identify what may need to be included in the audit and what information is irrelevant. Every member of the group audited the same five patients and the results were cross-referenced for any discrepancies. Each member of the group entered the same data. The audit tool was successful in the main, but some changes were needed. When writing details about appointments, it was difficult to find details about every appointment. Furthermore, it was going to be difficult to analyse results for more than one appointment. The decision was made to look at the first assessment appointment only. A box was then added for ‘outcome’ so rather than details about subsequent appointments, it would only be recorded as subsequent appointments arranged, new assessment appointment (e.g. if first was cancelled), treatment completed, patient discharged or treatment completed. Another addition to the audit tool after the pilot was a section recording past psychiatric referrals other than those related to gender dysphoria. The final change was removal of deed pole recording. It was found that some notes had a deed pole paper in them, but of those that didn’t the patients name may not have changed although this was not certain. It was suggested in some notes that the name was changed by deed pole but there was no official record of this.

Data Collection and Analysis:

All patients who were given their first assessment appointments at the Leeds GIDS Clinic from April 2005 to March 2006 were identified from records at the clinic and included in the audit. All data was retrieved from the patients clinical notes held at the Leeds GIDS and medical records and entered into the audit tool on Microsoft Excel. The Data was then analysed using the Statistical Package for the Social Sciences (SPSS).

Limitations:

• Due to time restraints only half of the audit cycle was completed. After any changes to the appointment system have been made, it should be audited at a later date.

• As the details we needed were not on a computer system, data collection came from notes so there was the chance of person errors. Some of the notes could not be found, which meant some patients had to be excluded.

• Only a small sample of patients were included in the audit. The clinic only had details recorded of patients with first appointments from April 2005 limiting data collection to one year. Ideally, more years should have been included in the audit making results more significant.

• It would have been useful to ask patients that ‘DNAd’ appointments reasons rather than relying purely upon speculation. Without ethical approval this was not possible.

Results (Appendix Two):

All Cases:

There were 50 patients who had their first appointment in the year 2005/2006. Out of the 50 patients notes for eight patients could not be located therefore these patients were excluded from the sample. Out of the remaining 42 patients, two further patients had to be excluded as they did not fit the inclusion criteria and had already started treatment elsewhere. Therefore the total number of patients in our sample, which were analysed, was 40 patients.

The average age for the sample population was 40 years (table one). Out of the patients analysed there were nine females wanting to become male. There were 30 males wanting to become female and one patient had this information missing (table two). The average waiting time for the first appointment for the whole of the sample population was 2.9 years (table one), and the average distance travelled by the whole sample population was 61.41Km (table one). Twenty five patients were not living with a partner, 14 patients were living with a partner and one patient had this information missing (table three). Thirty patients had no children, 10 had children (table four). In our sample, 22 patients did not have a past psychiatric history, 14 patients had a psychiatric history and four patients had the information missing (table seven).

For the first appointment, 26 patients attended, 12 patients ‘DNAd’ and two patients were excluded from analysis as the clinic cancelled their appointment. This gives us a DNA rate of 30% (table five). At the time of audit, four of the 12 patients who ‘DNAd’ their first appointment, four (33%) had been discharged due to serial non-attendance and the remainder had attended a second appointment (table six).

Comparing Attendance Group With Non-Attendance Group:

To further analyse our data we split our sample population into two groups one group was the Attended group and the other group was the DNA group. From our analysis; the average age of both groups was very similar (DNA = 40 years Attended = 40 years) (table eight). On average the Attended group waited 77 days longer for their first appointment than the DNA group (table nine). The DNA group only had males wanting to become female (12 males), whereas the attended group had 18 male and eight females (table 10).

Patients in the DNA group travelled an average of 70.3 Km whereas patients in the attended group only travelled a distance of 58.4Km (table 11). In the DNA group 75% of the people are from either social class 5 or below whereas in the Attended group only 50% are less than social class five or below (table 12). There is no difference between the percentages of patients in either group who are living with a partner (table 13). In the DNA group 83% of patients have no children whereas in the attended group only 73% had no children (table 14).

Patients are much more likely to DNA the appointment if it is at 10.00am compared to another time. Of 12 appointments that were not attended, 50% were at 10.00am and no other appointment time had a frequency greater than one. 66% of the appointments missed were in the morning and only 33% of the missed appointments were in the afternoon (table 15).

In the DNA group 25% of patients were discharged due to consecutive ‘DNAs’. In the attended group, only one patient (3.8%) was discharged due to two consecutive ‘DNAs’. In the DNA group only 33% were given a subsequent appointment whereas in the attended group 88.5% were given a subsequent appointment (table 16). In the DNA group 50% of patients had a past psychiatric history whereas in the attended group only 30% had a past psychiatric history (table 17).

Discussion:

The sample size used was very small, so it is difficult to come to any firm conclusions. Our results are not statistically significant. Some differences between the DNA group and the non-DNA group have become apparent.

The Leeds GIDS DNA rate during the year audited was 30%, categorising it as band one. The average for Leeds Mental Health Trust is band three indicating significant improvement is required. We have looked into potential reasons for the high DNA rate.

General Patient Factors:

Patients might think ‘it doesn’t affect me’, ‘it’s hard to contact the service’, ‘I’m not very well today’, ‘but I didn’t get the letter’, ‘I’m not ready to tell my family’ etc., which might be the cause for their DNA. By highlighting the need for patients to cancel appointments, and making sure it is easy to do so, hopefully patients will realise it is their responsibility.

Specific Factors

Surprisingly, waiting time and age had no effect on likelihood to DNA. Whether patients lived with their partner is less likely to influence their attendance, than the other factors studied. The difference in attendance rates between patients who had children and those who did not was negligible.

Patients who have to travel further are much more likely to DNA for their appointment compared to patients who live closer. Lack of transport and navigational factors are the most likely causative factors. It is difficult to eliminate this problem entirely.

The results suggest that people in lower social classes are much more likely to DNA their appointment. This may be because they find it difficult to get time off work, they are more likely to have transport problems, or can not read the clinic letters. Giving patients more choice about when in the day they have their appointment may reduce this.

Morning appointments were much more likely to be missed than appointments in the afternoon. Potential reasons include ‘sleeping in’, issues with childcare and problems with public transport. Again, giving the patient a choice of when they have their appointment may solve this.

Patients who ‘DNAd’ are more likely to be discharged without completing treatment implying that ‘DNAers’ are less dedicated to their gender change. Making patients more informed from the start may help them to make an informed decision earlier on.

The DNA rate was higher in patients with a past psychiatric history than those without. It is difficult to say whether this correlation is due to misdiagnosis of gender dysphoria, or a predisposition for patients with a psychiatric history to DNA.

Most of the causal links identified above are difficult to eliminate. The entire referral process (see below) was examined and improvements have been suggested to make patients better informed, and give them more choice.

Suggested changes to the service:

[pic]

After analysing letters used by the Clinic, it was suggested that a new protocol should be implemented- the rationale for this is explained overleaf.

[pic]

Rationale for and details of changes:

• Passive DNAs: “If you do not attend an appointment, and do not contact us, we will assume you do not require input” is written on many of the letters. If a patient does not attend their appointment and has not contacted the clinic, they have passively cancelled their appointment, so should not be offered any more, as they had indicated they do not require input. A passive cancellation is still a cancellation. Statements like this have been removed from all letters, to try and prevent passive cancellations.

• Clinic contactability: With growth of the Internet, email would be a good way for patients to contact Leeds GIDS and vice versa. Text Messaging (SMS) is popular. The Leeds Student Medical Practice reminds students booked in for long appointments the day before- giving the student plenty of time to cancel. This could be an idea for Leeds GIDS to adopt.

• Receipt of referral letter (Appendix three): A new more concise letter has been drafted (Appendix four). This informs patients of the waiting time for the clinic and alerts them to the leaflet and proforma, which are new suggestions to be included (see below).

• Leaflet (Appendix five): This was felt to be a good way of informing patients and GPs about Leeds GIDS. To minimise production costs, this leaflet is double sided A5 and in black and white allowing easy photocopying. This included directions and public transport details for the Becklin centre where clinics are held as it may be hard for local patients to find and harder for those who travel long distances to the clinics.

• Proforma (Appendix six): It is difficult to know what patients already know before they enter the service. It was felt that a short proforma would be a good way of collecting correct patient demographics and judging interest in the service. A patient who is unsure whether gender reassignment is for them may not return the proforma swiftly. To minimise appointments lost through last minute cancellation, a ‘last minute’ option was added with options for method of contact (e.g. phone, email). In addition, to address problems with people ‘DNAing’ early appointments, a option for preferred time of day has been included.

• First Appointment letter (Appendix seven): The suggested alternative letter (Appendix eight) has been reduced leaving out information that has been mentioned elsewhere (e.g. presence of students). The request for ten days notice to cancel an appointment in the current letter is not always possible, so a patient may prefer to DNA. The new letter ask only for ten days notice ‘where possible’.

• DNA letter (Appendix nine): This has been redrafted to include some ‘shock statistics’. Two separate DNA letters have been suggested – one for the first DNA offering another appointment (Appendix 10) and one for the second DNA informing the patient they have been discharged (Appendix 11).

Research Gaps:

By only looking at the first appointment, we are not taking into account people who are chronic ‘DNAers’. Their reasons for ‘DNAing’ may be multifactoral- this study can only attempt to guess the reasons, and eliminate them. A ‘DNAd’ first appointment may indicate a lack of commitment to the process.

Personal Reflections:

Our group has learnt many things from this audit, how to do an audit being one of the lesser components. We realised quite early on that a well done simple audit was must better than a poorly designed complicated audit, and responded by keeping it simple/ We found it tricky to differentiate between an audit and primary research, particularly as there were no original guidelines to follow. Our advice to future groups would be to keep motivated, and try to allocate tasks to the team depending on their personal strengths and weaknesses. We gelled well as a team, and have managed to not only produce a high standard audit, but forge new friendships, that will hopefully last beyond the audit.

Conclusion:

In conclusion, Leeds GIDS has a DNA rate of 30%. This is significantly worse than their pre-defined benchmark of equalling the Leeds Mental Health Trust (i.e 19.8%). Furthermore, a DNA rate of 30% puts Leeds GIDS into The Healthcare Commission’s “Band one” category – the lowest of five. The factors most strongly linked to DNAs were increasing distance travelled to clinic, early morning appointments and lower social classes. Suggestions on how to improve the DNA rate have been made- these include a change of protocol to remove passive ‘DNAs’, more patient choice for appointment time, re-written letters and improved methods of contacting the clinic. The audit cycle will need to be completed to see if the suggestions have improved the DNA rate.

References:

1) Wylie K. Gender related disorders. BMJ. 2004; 329: 615-617

2) World Health Organisation (2006). World Health Organisation’s website [Online]. [Last Accessed 6th June 2006]. Available from World Wide Web:

3) NHS Direct (2006). NHS Direct’s website [Online]. [Last Accessed 6th June 2006]. Available from World Wide Web:

4) Pffflin F, Bockting W, Coleman E. et al. International Journal of Transgenderism. 2001; 5(1). [Online]. [Last Accessed 6th June 2006]. Available from World Wide Web:

5) Reiner W. To Be Male or Female – That is the question. Arch Pediatric Adol Medicine. 1997; 151: 225

6) Wikipedia (2006) Wikipedia’s encyclopedia website [Online]. [Last Accessed 6th June 2006]. Available from World Wide Web:

7) Martin E, and Elevated Therapy (2000) A guide to gender dysphoria. Elevated Therapy’s website. website [Online]. [Last Accessed 6th June 2006]. Available from World Wide Web:

8) Deitch R. Broken NHS appointments: millions wasted? Lancet. 1984; 8391: 1419.

9) House of Lords Information Office. Speech by Baroness Jay of Paddington, 11 June. London: HoLIO, 1998. [Cited In Ref. 10]

10) Stone C, Palmer J, Saxby P, Devaraj V. Reducing non-attendance rates at outpatient clinics. J. R. Soc. Med. 1999; 92: 114-118

11) Committee of Public Accounts 42nd Report; NHS in England and Wales. HMSO, 1995.

12) Turner A, Cooke H. Are patients’ attitudes the cause of long waiting lists? Br J Clin Pract. 1991; 45: 97-98

13) Hamilton W, Round, A Sharp D. Effect on hospital attendance rates of giving patients a copy of their referral letter: randomised controlled trial. BMJ. 1999; 318: 1392-1395

14) Gatrad R. A completed audit to reduce hospital outpatients: non-attendance rates. Arch Dis Child 2000; 82: 59-61

15) Sharp D, Hamilton W. Non-attendance at general practices and outpatient clinics. BMJ. 2001; 323: 1081-1082

16) Killaspy H, Banerjee S, King M, Lloyd M. Prospective controlled study of psychiatric out.patient non.attendance. Characteristics and outcome. Br J Psychiatry. 2000; 176: 160-165

17) Lacy L. Paulman A, Reuter M, Lovejoy B. Why we don’t come: patient perceptions on no-shows. Annals of Family Medicine. 2004; 2(6): 541-545

18) Ritchie J, Dick D, Lingham R. (1994) The report of the enquiry into the care and treatment of Christopher Clunis. London: HMSO

19) The Healthcare Commission (2006). The Healthcare Commission’s website [Online]. [Last Accessed 6th June 2006]. Available from World Wide Web:

20) Google (2006) Google – Internet Search Engine. [Online]. [Last Accessed 6th June 2006]. Available from World Wide Web:

Appendix One: Audit Tool

[pic]

Appendix Two: Results Tables

All Cases:

Table one: Overall Averages

| |N |Range |Minimum |Maximum |Mean |Std. Deviation|Variance |

|

| |Statistic |Statistic |Statistic |Statistic |Statistic |Std. Error |Statistic |Statistic |

|

|AGE |40 |42 |61 |19 |40 |1.93 |12.199 |148.813 |

|

|Distance (KM) |40 |161 |9 |170 |61.41 |6.70 |42.395 |1797.359 |

|

|Waiting Time |40 |4.16 |.92 |5.08 |2.9198 |.1619 |.99778 |.996 |

|

Table two: Sex

| |Frequency |Percent |Cumulative Percent|

|

|Information missing |1 |2.5 |2.5 |

|

|Female |9 |22.5 |25.0 |

|

|Male |30 |75.0 |100.0 |

|

|Total |40 |100.0 | |

|

Table three: Living with Partner

|Living with partner |Frequency |Percent |Cumulative Percent|

|

|Information missing |1 |2.5 |2.5 |

|

|No |25 |62.5 |65.0 |

|

|Yes |14 |35.0 |100.0 |

|

|Total |40 |100.0 | |

|

Table four: No. Of Children

|No. Of children |Frequency |Percent |Cumulative Percent |

|

|0 |30 |75.0 |76.9 |

|

|1 |3 |7.5 |84.6 |

|

|2 |3 |7.5 |92.3 |

|

|3 |1 |2.5 |94.9 |

|

|4 |2 |5.0 |100.0 |

|

Table five: Attendance

|Attendance |Frequency |Percent |Cumulative Percent |

|

|Excluded |2 |5.0 |5.0 |

|

|DNA |12 |30.0 |35.0 |

|

|Attended |26 |65.0 |100.0 |

|

|Total |40 |100.0 | |

|

Table six: Outcome

| |Frequency |Percent |Cumulative Percent |

|

|Treatment complete |5 |12.5 |12.5 |

|

|DNA Discharge |4 |10.0 |22.5 |

|

|Subsequent appointment |27 |67.5 |90.0 |

|

|Lost to follow up |4 |10.0 |100.0 |

|

|Total |40 |100.0 | |

|

Table seven: Past Psychiatric History

|Past Psychiatric History|Frequency |Percent |Cumulative Percent |

|

|Information missing |4 |10.0 |10.0 |

|

|No |22 |55.0 |65.0 |

|

|Yes |14 |35.0 |100.0 |

|

|Total |40 |100.0 | |

|

Comparing Attendance Group With Non-Attendance Group:

Table eight: Age

| |N |Range |Minimum |Maximum |Mean |Std. Deviation|Variance |

|

|Attendace |Statistic |Statistic |Statistic |Statistic |Statistic |Std. Error |Statistic |Statistic |

|

|Excluded |2 |18 |40 |58 |42.23 |2.14 |3.030 |9.180 |

|

|DNA |12 |39 |19 |58 |40.69 |3.54 |12.279 |150.779 |

|

|Attended |26 |39 |22 |61 |40.44 |2.52 |12.846 |165.019 |

|

Table nine: Waiting Time

| |N |Range |Minimum |Maximum |Mean |Std. |Variance |

| | | | | | |Deviation | |

|

|Attendance |Statistic |Statistic |Statistic |Statistic |Statistic |Std. Error |Statistic |Statistic |

|

|DNA |12 |3.88 |.92 |4.80 |2.7765 |.3446 |1.19388 |1.425 |

|

|Attended |26 |3.69 |1.39 |5.08 |2.9860 |.1789 |.91207 |.832 |

|

Table 10: Sex

|Attendance |Sex |Frequency |Percent |Valid Percent |Cumulative Percent |

|

|Excluded | |2 |100.0 |100.0 |100.0 |

|

|DNA |Male |12 |100.0 |100.0 |100.0 |

|

|Attended |Female |8 |30.8 |30.8 |30.8 |

|

| |Male |18 |69.2 |69.2 |100.0 |

|

Table 11: Distance

|Attendance |N |Range |Minimum |Maximum |Mean |Std. |Variance |

| | | | | | |Deviation | |

|

|Attendance |Statistic |Statistic |Statistic |Statistic |Statistic |Std. Error |Statistic |Statistic |

|

|Excluded |2 |56 |20 |76 |47.55 |27.95 |39.527 |1562.405 |

|

|DNA |12 |143 |9 |152 |70.28 |13.53 |46.867 |2196.483 |

|

|Attended |26 |161 |9 |170 |58.38 |8.12 |41.379 |1712.202 |

|

Table 12: Job class

|Attendance |Job Class |Frequency |Percent |Valid Percent |Cumulative |

| | | | | |Percent |

|

|Excluded |2 |1 |50.0 |100.0 |100.0 |

|

|DNA |1 |1 |8.3 |12.5 |12.5 |

|

| |3 |1 |8.3 |12.5 |25.0 |

|

| |5 |1 |8.3 |12.5 |37.5 |

|

| |6 |2 |16.7 |25.0 |62.5 |

|

| |7 |3 |25.0 |37.5 |100.0 |

|

|Attended |2 |6 |23.1 |25.0 |25.0 |

|

| |3 |3 |11.5 |12.5 |37.5 |

|

| |4 |3 |11.5 |12.5 |50.0 |

|

| |6 |4 |15.4 |16.7 |66.7 |

|

| |7 |8 |30.8 |33.3 |100.0 |

|

Table 13: Living with Partner

|Attendance |Living with |Frequency |Percent |Valid Percent |Cumulative Percent |

| |partner | | | | |

|

|Excluded | |1 |50.0 |100.0 |100.0 |

|

|DNA |No |8 |66.7 |66.7 |66.7 |

|

| |Yes |4 |33.3 |33.3 |100.0 |

|

|Attended |No |17 |65.4 |65.4 |65.4 |

|

| |Yes |9 |34.6 |34.6 |100.0 |

|

Table 14: No. Of Children

|Attendance |No. Of |Frequency |Percent |Valid Percent |Cumulative Percent |

| |Children | | | | |

|

|Excluded | |1 |50.0 |100.0 |100.0 |

|

|DNA |0 |10 |83.3 |83.3 |83.3 |

|

| |2 |1 |8.3 |8.3 |91.7 |

|

| |3 |1 |8.3 |8.3 |100.0 |

|

|Attended |0 |19 |73.1 |73.1 |73.1 |

|

| |1 |3 |11.5 |11.5 |84.6 |

|

| |2 |2 |7.7 |7.7 |92.3 |

|

| |4 |2 |7.7 |7.7 |100.0 |

|

Table 15: Time

|Attendance | |Frequency |Percent |Valid Percent |Cumulative |

| | | | | |Percent |

|

|Excluded |. |2 |100.0 |100.0 |100.0 |

|

|DNA |1000 |6 |50.0 |50.0 |50.0 |

|

| |1100 |1 |8.3 |8.3 |58.3 |

|

| |1200 |1 |8.3 |8.3 |66.7 |

|

| |1300 |1 |8.3 |8.3 |75.0 |

|

| |1400 |1 |8.3 |8.3 |83.3 |

|

| |1500 |1 |8.3 |8.3 |91.7 |

|

| |1600 |1 |8.3 |8.3 |100.0 |

|

|Attended |0900 |1 |3.85 |3.85 |3.85 |

|

| |1000 |10 |38.46 |38.46 |42.31 |

|

| |1100 |3 |11.54 |11.54 |53.85 |

|

| |1200 |3 |11.54 |11.54 |65.39 |

|

| |1300 |3 |11.54 |11.54 |76.93 |

|

| |1400 |3 |11.54 |11.54 |88.47 |

|

| |1500 |2 |7.69 |7.69 |96.16 |

|

| |1700 |1 |3.85 |3.85 |100.0 |

|

Table 16: Outcome

|Attendance |Outcome |Frequency |Percent |Valid Percent |Cumulative Percent |

|

|Excluded | |2 |100.0 |100.0 |100.0 |

|

|DNA |Treatment complete |5 |41.7 |41.7 |41.7 |

|

| |DNA discharge |3 |25.0 |25.0 |66.7 |

|

| |Subsequent appointment |4 |33.3 |33.3 |100.0 |

|

|Attended |DNA Discharge |1 |3.8 |3.8 |3.8 |

|

| |Subsequent appointment |23 |88.5 |88.5 |92.3 |

|

| |Lost to follow up |2 |7.7 |7.7 |100.0 |

|

Table 17: Past Psychiatric History

|Attendance |Past Psychiatric History |Frequency |Percent |Valid Percent |Cumulative Percent |

|

|Excluded | |2 |100.0 | | |

|

|DNA |No |6 |50.0 |50.0 |50.0 |

|

| |Yes |6 |50.0 |50.0 |100.0 |

|

|Attended |No |16 |61.5 |66.7 |66.7 |

|

| |Yes |8 |30.8 |33.3 |100.0 |

|

Appendix Three: Current Receipt of Referral Letter

[pic]

Appendix Four: Suggested Receipt of Referral Letter

Leeds Mental Health NHS

Teaching NHS Trust

Leeds Gender Identity Service

The Becklin Centre

Alma Street

Leeds

LS9 7BE

Tel& Fax: 0113 3056737

Email:

Our ref: JW/GJC/new

Private and Confidential

Dr Someone

Medical Centre

Health Park

Portobello Road

Town

Postcode 1 May 2006

Dear Doctor

Re: Mr Patient, DOB, NHS

Address

Thank you for your recent referral for your patient.

We are writing to inform you that Mr X has been placed on the waiting list for the Leeds Gender Identity Service. We have to make you aware that we have an extensive waiting list, but we will send your patient an appointment as soon as possible.

Can we please take this opportunity to ask you that if your patient changes address or any contact details that you inform us.

We have enclosed a leaflet about the gender identity service in Leeds, which may be of interest to you and your patient.

Yours sincerely

Joanne Walkinshaw

Clinical Team Manager

Leeds Gender Identity Service

Copy: Patient & Locum Consultant Psychiatrist

Appendix Five: Suggested Leaflet

[pic]

Appendix Six: Suggested Proforma

Dear Patient,

Please read and sign the attached form. Your name will be placed on the waiting list as soon as we receive the completed form.

I agree with my Doctors decision to refer me for Gender reassignment. I understand that:

• The waiting list is approximately four years

• I can change my mind at any point before commencing treatment

• It is my responsibility to inform the clinic if I am unable to attend appointments, no longer require the service, or change my address or contact details.

• If I miss two consecutive appointments without contacting the clinic, they will remove me from their waiting list.

Preferred time of appointment:

❑ Early AM

❑ Late AM

❑ PM

❑ Any

I am/am not willing to be offered a first assessment appointment at short notice.

Preferred method of contacting:

❑ SMS

❑ Mobile

❑ Landline

❑ Email

Address:

Phone Number: Mobile Number:

Email Address:

Name: Signed:

Appendix Seven: Current First Assessment Letter

[pic]

Appendix Eight: Suggested First Assessment Letter

Leeds Mental Health NHS

Teaching NHS Trust

Leeds Gender Identity Service

The Becklin Centre

Alma Street

Leeds

LS9 7BE

Tel& Fax: 0113 3056737

Email:

Our ref:

1 May 2006

Dear

A first assessment appointment has been made for you to see Dr X and the Clinical Nurse Specialist Y, at the Leeds Gender Identity Service. Your appointment is on:

Appointment time and date here

We have included a life history questionnaire. Please complete this and send it back to us at the above address, at least one week before your appointment. This information will speed up the assessment process.

On arrival at the Becklin Centre, please check in at Outpatients Reception, to make then aware that you have arrived for your appointment. We will meet you in the waiting area.

As we only have a limited number appointments available for first assessment, please do your best to attend at the given time and date. If you are unable to attend for this appointment, please let us know as soon as possible (preferably at least 10 days in advance) so that we can rearrange a time for you.

If you are receiving treatment elsewhere, or no longer require our service, please let us know.

Yours sincerely

Joanne Walkinshaw

Clinical Team Manager

Leeds Gender Identity Service

Appendix Nine: Current DNA Letter

[pic]

Appendix 10: Suggested First DNA Letter

Leeds Gender Identity Service

The Becklin Centre

Alma Street

Leeds

LS9 7BE

Tel& Fax: 0113 3056737

Our Ref:

Date:

Dear

First Missed Appointment

I note that you did not attend for your first assessment appointment with our service ____________________. We will offer you one more appointment before discharging you from our service.

Missed appointments cost the NHS £65, with longer appointments, like appointments at the Gender Identity Disorders Service, as well as wasting valuable clinician time. Other resources like clinic rooms and medical equipment are also booked up when they might have been used elsewhere. The effects of non-attendance contribute to patient waiting lists, inconveniencing other people who are waiting to be seen as quickly as is possible. Outpatient non-attendance might increase waiting lists by anything from one week to six months. This is all in addition to the frustration that staff experience when patients are absent from clinic without warning.

In 2005-6, the Leeds Gender Identity Disorders Service had a 30% missed first appointment rate. This puts us as one of the worst performing specialities in the Leeds Mental Health Trust.

If you are unable to attend your next appointment, please let us know as soon as possible so that we can offer the appointment to someone else. If you no longer require our services, we will discharge you from the service.

Yours sincerely,

Appendix 11: Suggested Second DNA Letter

Leeds Gender Identity Service

The Becklin Centre

Alma Street

Leeds

LS9 7BE

Tel& Fax: 0113 3056737

Our Ref:

Date:

Dear

Second Missed Appointment

I note that you did not attend for your first assessment appointment with out service on ___________________. As you have now missed two first assessment appointments, we are discharging you from our service.

Missed appointments cost the NHS £65, with longer appointments, like appointments at the Gender Identity Disorders Service, as well as wasting valuable clinician time. Other resources like clinic rooms and medical equipment are also booked up when they might have been used elsewhere. The effects of non-attendance contribute to patient waiting lists, inconveniencing other people who are waiting to be seen as quickly as is possible. Outpatient non-attendance might increase waiting lists by anything from one week to six months. This is all in addition to the frustration that staff experience when patients are absent from clinic without warning.

In 2005-6, the Leeds Gender Identity Disorders Service had a 30% missed first appointment rate. This puts us as one of the worst performing specialities in the Leeds Mental Health Trust.

If you wish to use the clinic services in the future, please contact your GP, who will re-refer you.

Yours sincerely,

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download