Why is the Sandyford wait time so long? What the numbers can tell us.

Why is the Sandyford wait time so long? What the numbers can tell us.

15-20 minute read.

CN: towards the end of this article there is mention of suicide. This article discusses in-depth the operation of Sandyford GIC including information about number of appointments offered and waitlist increases, and may prove an upsetting read to trans people currently waiting to be seen by Sandyford in particular.

New data has been released on the UK’s Gender Identity Clinics (GICs), revealing that Glasgow’s Sandyford is dramatically underperforming compared to comparable clinics such as Chalmers in Edinburgh. Despite an increase in budget and staff capacity, the number of appointments per year has decreased. While referrals have increased by 31.2%, the number of people on the waiting list has increased by 338.5% and the clinic is providing fewer appointments than five years ago. This raises questions about what is going on inside Sandyford that it is failing trans people in Glasgow and surrounding areas so badly.

Sandyford is Glasgow’s GIC, and one of four Scottish GICs alongside Chalmers (Edinburgh), Grampian, and Highlands. It is the sole provider of youth gender services in Scotland. In August of this year, educator and researcher Claire, founder of Claire’s Trans Talks, compiled and released data on the performance of adult GIC services in the UK, obtained through data available on clinic websites and several Freedom of Information (FOI) requests served to the NHS. The data covers referral numbers, waiting list length, appointments conducted, contracted staff hours, and clinic budget, over the period covering 2018-2023. With a couple of notable exceptions, the data paints a shocking picture. The majority of UK GICs have experienced a huge increase in waitlist length that is totally incommensurate with the number of new referrals, because they are providing fewer appointments despite increasing their budget and staff capacity.

Why are clinics providing worse services with more resources? There are serious questions that need to be answered by almost all of the GICs. The national picture is grim: trans patients are being failed, and are seeing none of the benefits of the increased resources being put into these clinics. And Sandyford is performing worse than its most similar peers.

Let’s lay out the numbers plainly first. This is Sandyford from 2018-2023:

• Number of referrals per year increased 31.2%
• Wait list volume increased 338.5%
• Clinic budget increased 149.6%
• Clinical staff capacity increased 96.6%
• Initial appointments offered per year decreased 86.1%
• Total appointments offered per year decreased 18.8%

On their own, these numbers raise questions about the contradiction between increased resources and decreased service provision. But the questions rapidly multiply when Sandyford is compared to other GICs and the data is examined in more detail.

How does Sandyford compare to other clinics?

Before making comparisons, it’s worth noting that the other gender clinics are not providing a good service. Almost every clinic in the country has had an an increase in waitlist that is disproportionate to the number of referrals received, and almost all of them are providing fewer appointments than five years ago, not more. The numbers don’t reflect everything either: take the recent news out of Chalmers about the pause on surgery referrals. The point of these comparisons isn’t that other clinics are succeeding where Sandyford is not. All of them are failing, but somehow, Sandyford is doing even worse.

In terms of how many referrals were received during the 2022-23 period, Sandyford is closest to Nottingham GIC. From 2018-23, Nottingham GIC saw a 6% increase in referrals and a corresponding 14% increase in waiting list length, which is similar to other Sandyford-like clinics such as Chalmers in Edinburgh and miles better than Sandyford itself. Nottingham has almost triple Sandyford’s budget, but also has significantly more patients overall (just over double, based on the number of referrals across all years).

Comparing budgets then, Sandyford is closest in its amount of funding to the Welsh Gender Service, but is similar to Nottingham in the proportional increase in its budget since 2019. The Welsh Gender Service is the best performing service in the country by the numbers, being one of the few that has managed to reduce its waitlist. Nottingham similarly outperforms Sandyford in terms of their waitlist management in proportion to referral increases.

It’s worth comparing Sandyford to Chalmers in Edinburgh, as they are the two largest GICs in Scotland. Due to healthcare being a devolved matter, the Welsh Service operates differently to English and Scottish clinics (going by the numbers, it’s operating much better), which again vary due to differences between NHS England and NHS Scotland. There are also the Grampian and Highlands GICs, but they are so much smaller in terms of patient numbers that the data is difficult to meaningfully compare.

Historically Chalmers has had fewer referrals per year, but in 2022-23 their numbers were close to those of Sandyford. This suggests a greater increase in service demand relative to prior provisions, but the increase in waitlist size at Chalmers is less than half that at Sandyford. Chalmers has increased its diagnostic staff capacity significantly more than Sandyford, but both clinics increased their clinical staff capacity by similar amounts. Both also saw an increase in budget from 2018-2023, though Chalmers had less money per patient referred. Despite their general similarities and Sandyford’s overall greater increase in resources, Chalmers has increased the number of appointments offered per year by 30% since 2018, while the number offered by Sandyford has decreased by nearly 19%.

* Chalmers has a listed diagnostic staff capacity greater than their overall clinical capacity for the period 2022-23, due to how the average annual FTE was calculated by the clinic.

** As Sandyford had more referrals than Chalmers prior to 2022-23, estimating the number of patients based on referrals is likely to be a greater underestimate than it is for Chalmers. It is therefore likely that the budget per patient calculated from overall patient numbers would be closer in value than the figures here suggest. Unfortunately we were not able to obtain data on the total number of patients being seen and waiting to be seen for either clinic.

*** Calculated as number of patients per unit of FTE clinical staff capacity

Why is Sandyford performing so badly?

In order to answer this question, the first step is to look for statistical features unique to Sandyford. An example would be the 7% decrease in administrative staff capacity since 2018, which is the only recorded decrease outside London. As most clinics have not invested much into administration, it is unclear whether this could fully explain the decrease in appointments, particularly initial appointments, given the increase in clinical staff and budget. There is no dramatic increase in the number of other appointments that would explain the decrease in initial appointment numbers. Again the question arises: where are the money and staff hours going, if not on offering appointments?

Chalmers, Nottingham, and Wales are some of the most comparable services to Sandyford in terms of patient numbers, budget, and in the case of Chalmers also being part of NHS Scotland. These peer clinics are three of only four clinics in the UK to be offering a greater number of initial appointments than in 2018-19 (the fourth is Belfast). Judged next to its most similar peers in particular, Sandyford is shockingly bad.

As of 2022-23, Sandyford had 5.7 FTE clinical staff capacity, compared to 11 in the Welsh service, and 4.95 at Chalmers. But of that clinical capacity, only 2.11 FTE comprised diagnostic and assessment capacity at Sandyford, compared to 4.6 in the Welsh service and 5.22 at Chalmers. Sandyford had around triple Chalmers’ budget for the 2022-23 period, and around triple the overall waitlist volume (Chalmers took in a similar number of referrals during this period, but fewer in previous years). Compared to the Welsh service, it has a slightly smaller budget, but over double the waitlist volume for the 2022-23 period.

Comparing staff capacity (both clinical and diagnostic, as measured by annual FTE hours) to the most recently recorded waiting list volume, Sandyford is worse than every other GIC except London, to which it is similar. 

It is almost impressive that Sandyford shows similar numbers of patients per staff capacity despite being a significantly smaller clinic than London. Both clinics also provided youth gender services during the period of data collection (Tavistock and Portman GIDS has since been closed; Sandyford’s youth service still operates). It’s possible this impacted their performances. Though the adult and youth services operate on separate budgets, there may have been other resources (such as staff hours) that were split between the two. Youth services have been criticised by trans people for their waiting times and lack of care provided, so if this diversion of resources has occurred, it has been of little apparent benefit to anyone. The fact that both are youth service providers could also simply be a coincidence.

The main unique feature of Sandyford’s data that could provide a clue as to why it is performing so badly is tracking its annual average staffing capacity alongside the number of appointments:

This chart shows the number of appointments (bars, left-hand y-axis) and the clinic’s staff capacity in annual FTE (lines, right-hand y-axis). There was a drop in clinical capacity through 2019-21, and while the total number of appointments did somewhat recover once capacity was increased, the number of initial appointments did not. In addition, while initial appointments halved from 2018-19 to 2019-20 coinciding with the dip in capacity, they halved again in 2022-23 after remaining roughly constant in the previous three years. This is despite a concurrent increase of almost 3 FTE in clinical capacity. If this previous decrease in capacity created a backlog that is to blame for the lack of appointments, then this raises two questions: why was the impact so bad at the time, and why has the clinic not been able to recover in spite of having a greater staff capacity and budget than ever before?

One possible answer is that staff capacity and budget per person on the waitlist are around half what they were in 2018-19, though higher than during the pandemic. But that does not explain everything. The value of the budget per person at Sandyford during 2022-23 is the same as what Chalmers has been running at for the last five years, and as has been discussed they provide a better service (on paper) with these resources. Chalmers has 2-3 times as much clinical capacity per person on the waitlist than Sandyford and has also increased the proportion of their total appointments that are first appointments since 2018. This is not necessarily a good thing: therapeutic, endocrine, and surgical treatments are not possible until after a second appointment, but the numbers show Sandyford have not increased their offerings of follow-up appointments to prioritise ongoing care either. As previously mentioned, the overall number of appointments offered has decreased since 2018. In 2022-23, Sandyford offered just 47 initial appointments—less than one per week.

What can be learned from this?

It’s possible to conduct all manner of complex statistical analyses and hypothesise what could be going on, but it’s impossible to know from the outside. We have reached out to Sandyford for comment.

In the meantime, trans people in Glasgow continue to experience far longer wait times than those elsewhere in Scotland. While this data tells us about how clinics are being run, it doesn’t tell us how long people are waiting. Fortunately, both Chalmers and Sandyford list this information on their website. So, at time of writing:

Chalmers – Allocating first appointments for referrals from July 2023 (17 months)

Sandyford – Allocating first appointments for referrals from November 2018 (71 months)

Freedom of Information (FOI) requests from last year indicate wait times of around two years for the significantly smaller Grampian and Highlands GICs, so Sandyford is also falling behind compared to them (and that’s not to say that waiting 17-24 months is reasonable either). It is simply not clear from the data what is stopping Sandyford from meeting the standards of its peers. There are some discrepancies in staffing capacity and budget compared to patient numbers, but with similar changes to budget Chalmers have been able to improve their service much more than Sandyford.

With years-long wait times everywhere in the UK, many trans people turn to shared care (where a GP prescribes on the advice of privately practicing trans health professionals) or other methods of medical transition. Difficult as this can be to do anywhere in the UK, once again Glaswegians hit another additional snag. NHS Greater Glasgow and Clyde (GGC) has no Shared Care Agreements covering oestrogen, testosterone, progesterone, or testosterone-blockers, which means that many GPs refuse to undertake shared care or courtesy prescribing. This shuts trans people in Glasgow out of this potential alternative that some are able to afford. Anecdotally, many GPs also refuse to do blood tests for patients who obtain hormones outside the GIC.

Numbers and data aside, this situation has a human cost, once which is well-known across the trans community. Tam, a transmasculine person who was referred to Sandyford around seven years ago, has mostly transitioned through private and ‘DIY’ methods: ‘I’ve technically had my first appointment, during which they didn’t bother mentioning I might be waiting a year for my second one’. Quinn, a transfeminine person, described the ‘overwhelming hopelessness’ of being on the waitlist. Like Tam, she experienced a long wait after her first appointment before she could access treatment, which she described as excruciating, telling us: ‘if I was rejected for treatment, I had a plan to end my life’. They accrued debt from accessing private medical treatment and has since switched to DIY methods for accessing hormones. Several people told us about being unable to afford the cost of private healthcare, especially where a lack of GP support meant they also had to access blood tests and prescriptions privately. Willow, who self-referred in 2022 and also accesses hormones via DIY, said they felt that either Sandyford

The simple fact when it comes to Sandyford is that the numbers do not add up: more funding and more clinical staff, but fewer appointments provided and a hugely increasing waiting list. Where the money and staff hours are going is unclear, but it doesn’t seem to be benefiting patients.

You can find the full tables of data on the UK’s GICs published by Claire here. 

What The Trans have reached out to Sandyford for comment. All names of people quoted have been changed for privacy.

We understand that this was likely a difficult read for our trans readers. If you are struggling and need support, please reach out to one of these organisations:

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