Friday, 18 November 2011

The death of the NHS Walk-In Centre

One of the better changes introduced to the UK National Health Service (NHS) was the concept of Primary Care Walk-In Centres. They were located primarily in urban or city locations and were available to the public from 7am to 10pm for 364 days a year. In other words they were available at a time convenient to the public rather than a time convenient to local General Practitioners (GP).
The Walk-In centres were staffed by teams of highly skilled primary care nurses and led by autonomous Primary Care Nurse practitioners. The procedures and skills of the nurses, who were qualified to prescribe a full range of drugs and medicines, mean that they could deal with 98% of the cases without the need for a medical GP. For those few where the nurses could not handle a GP would be be employed on a part time basis by the lead Nurse Practitioner.
No appointment was necessary, people could literally walk in off the street and receive a medical consultation. Those with long term medical conditions would be given any necessary urgent treatment and referred back to their GPs for long term primary care.
The concept was extremely successful:
  • The costs were low. A WIC patient consulation was about £25 cost to the NHS. If that patient had gone a GP it would have cost at least the NHS at least £35. If the patient couldn't get to see a GP and decided to go to the local Accident and Emergency the minimum cost to the NHS would be £105.
  • Waiting times were good. Patients were seen within an average of 20 minutes or less in a fully staffed WIC.
  • The GP practices in the UK are run by independent contractors. They could turn patients away or close for the day at the whim of the GP Partners. The WIC teams were obliged to stay open, requiring permission from the local Primary Care Trust (PCT) and the Dept of Health before they could close.
  • The WICs helped to reduce queues in the local Accident and Emergency departments when patients with minor ailments were "streamed" away from the Hospital to the Walk-In Centre.
  • The WICs had a very low medical error/claim rate.
Sadly now most of the Primary Care Walk-In Centres have now been closed and their skilled teams of nurses dispersed. There are other reports on the Internet. In some cases the closures are hidden by the retention of a couple of junior staff and assigning them to a local GP or an A&E department. With the GP led Walk-In Centres you will see the daily open hours change from 0700-2200 to something like 0800-1900. In some cases the nurses are transferred to Acute Trust (Hospital) where the nurses role is subtly changed from being trained autonomous medical practitioners who diagnose and prescribe. Now they have to double check any decision with expensive doctors.

Originally the funding of the WIC team came centrally from the Dept of Health, it was ringfenced and could not be diverted to other purposes. Subsequently the ringfenced funding was merged into the general funding of the Primary Care Trusts. Opponents of WICs soon diverted the funding away from the WICs and the closures started. Remember the WICs often dealt with the failures of the GPs. They were seen as a threat to their profits. When the Conservative/Liberal coalition government came to power the scourge of the NHS in the shape of Andrew Lansley was released. He decided to wipe out the Primary Care Trusts and to hand the financial reins to the local GPs.  GPs see WICs as financial competition. It signalled the end of the PCT funded Walk-In Centres. Some have been absorbed by the budget hungry Acute Trusts (hospitals) to act as a streaming front end to A&E purely intended to prevent breaches of the waiting time targets. The Acute Trust, typically struggling under the financial burden of a PFI project, gains the funding from the Walk-In Centre, but the public lose the benefits.

These facilities are closed without public consultation, possibly leaving a ghost service to protect against public follow-up. The health administrators hate having their closure plans examined in public. Hundred's of thousands of pounds will have been spent in creating each of these Centres. It is often wasted. In one case the building was handed over to a local GP (private) in another the buildings will be demolished to provide parking spaces.

The consequence of these widespread WIC closures in London will be felt with greater queues in A&E, particularly at the time of the Olypmics 2012. Some of these walk-in centres were due to provide support to visitors. Here's a BBC report of a typical example in Surrey. They used to have a local WIC but it closed. You'll see a similar pattern in Croydon, New Cross, Whitechapel (E1), Homerton, Canary Wharf, Liverpool Street, Victoria and many other locations such as Stapleford, Ashfield, Leeds, Derby, Bradford, Salford, Harrow, Nottingham, Kirby, Trafford, Bromley, Manchester, Southampton , Barnsley, Warrington York Haverhill (Suffolk) Loughborough

An attempt to close Peterborough WIC.

Update: Late Nov 2011  One of the Walk-In Centres scheduled for closure soon,  as usual had a busy day as people attended for treatment yesterday. Many of those people would have gone to the local A&E Dept. Needless to say, the nearby A&E Dept managers are wetting themselves at the prospect of a 40% uplift in visits when the Walk In Centre closes. The A&E waiting time targets are going to be shattered, they already fail to meet waiting targets frequently enough as it is on present levels of patients.

Update Feb 2013: To make matters worse the local A&E Departments, which were protected by the Walk-In-Centres taking part of the load, are getting closed down as part of the service cuts. The (private) GP led Walk-in-centres open just 13 hours a day 8 - 7pm compared with Nurse led (NHS) 16 hours and the GP WICs have significantly reduced staff levels.


  1. This is a response from Dr Una Coales:
    " thanks for link. IMHO nurse run walk in centres are like NHS direct, algorithm care often ends up with see your GP or go to A&E."

    She's a GP who happens to be "Conservative Health Secretary,NHS locum GP,RCGP Council Rep,author&MRCGP courses educator.Presented C4's TBYBC (UK,Oz,BBC America,NZ,Canada,BBC Lifestyle Asia)"

  2. The WIC is not an extremely successful concept unless you are one of the worried well or someone who expects the NHS to cater to their every convenience.

    Those of us working in the NHS will be able to recount plenty of anecdotes of poor treatment by WICs - often the result of expecting nurse practitioners to diagnose undifferentiated illness (something which they are manifestly less able to do than someone who has been to medical school). You also fail to highlight the duplication of services - the vast number of people who are referred on from WICs back to their GP or to A+E departments.

    Of course, these are anecdotes and not evidence. But I'm afraid I don't believe your figures for one moment. I don't know where you come up with the cost of £35 for a GP attendance. GP practices are paid a set fee each year for each of their patients (I believe it is around £56). They are not paid per consultation.

    I agree about the waste of resources on closing these centres. I just wish they had never been opened in the first place.

  3. @BoatBuilder - Sadly the Coales comment is a typical biased smeer unsupported by fact. The WICs usually keep records of why the patient attends the WIC and not their GP. A good proportion of the attendees are either "Could not get an appointment" or "Don't want see my GP." WICs refer patients back to their GP if the condition is long term and should be properly dealt with by the GP. What is worrying is that this person is in the position to have the ear of Andrew Lansley.

    As to Dr James. Those cost figures are published data - do your own research.
    You claim the "vast number" of patients are referred to GP's or A&E; do you have any statistics to support this view (hint - I've seen the figures)?
    Dr James might also want to double check on the actual qualification required of a Primary Care Nurse Practitioner, once again the term "manifestly" is misleading, akin to propaganda.

  4. Mr Adair

    I'm perfectly capable of doing my own research. It is just that I can't for the life of me find where you have got your figures from.

    These are the costs in Nottingham;

    • Stapleford £868,000 a year - 22,000 patients cost approximately £40 for each visit.
    • Ashfield £463,000 a year - 15,000 patients cost approximately £30 for each visit.

    They were closed because they do not provide value for money.

    As I have already pointed out to you - a GP gets paid a minimum of around £56 for the entire care of one patient OVER A YEAR (+ enhanced services and outcome payments).

    Your claims seem quite at odds with what those of us working in the health service experience. I'm curious, therefore, as to where your figures come from. I'm also curious as to whether you can point me in the direction of any published evidence as to whether WICs reduce A+E attendances.

    II think WIC had the capacity to both help and hinder ED crowding - having scanned the medical literature I can't find any rigorous evidence to settle the debate.

    Now, as to my use of the word 'manifestly' - which I take to mean something that is clear or obvious. Now, funnily enough being someone who works in healthcare, I understand very well what is required of the qualifications of a primary care nurse practitioner.

    There is, in fact, no agreed standard as to what training a nurse practitioner, consultant nurse, advanced nurse practitioner, etc., should undergo. There is no additional regulation of standards from the nursing and midwifery council when these titles are conferred.

    The RCN recommends that they should undertake a specific course of study to honours degree level. These course are usually delivered on a part time basis over 2-4 years and include teaching and training on examination and diagnostic skills. They almost invariably include a course of study allowing the candidates to become non-medical prescribers. Here is an example;

    As an aside, the term 'medical practitioner that you use refers only to a doctor, not a nurse. Nurses may be practitioners but they do not practice medicine. In fact, nurse practitioners almost always work within the confines of protocols and guidelines developed by supervising doctors.

    To become a doctor one must first complete 5 years of full time training to a much more rigorous standard. To become a fully registered medical practitioner a further 12 months of full time clinical experience rotating through medicine and surgery is required. To become a specialist in general practice a further 4 years of full time postgraduate training is necessary.

    Given this, I do not believe it is misleading to say that it is obvious that a doctor is better qualified to diagnose and manage undifferentiated disease than a nurse practitioner.

    And finally - your point about expensive doctors. I have been a doctor for 5 years. I am of sufficient seniority that at times I am the most senior person available at night in the hospital for my specialty. My pro-rata pay is less than that of a nurse practitioner.

    I'm quite happy to point you towards the evidence for what I say. Of course I have a bias in how I interpret it. Could you show me where your evidence is for the propaganda about WICs being extremely successful?

  5. For the avoidance of doubt - I respect my nursing colleagues very much. They do a difficult job and we rely heavily upon their support.

    I think many of those working in extended roles also offer a valuable contribution.

    I do not think it is sensible to extend their role into that of diagnosing and managing undifferentiated illness - this is the raison d'etre of doctors. It is what our training is geared towards.

    Those nurses who think that a nurse practitioner course equips them with the skills of a doctor (and I'm afraid these people do exist) are dangerous.

  6. Dr James. Ah I see you are a Doctor in an acute hospital? I have no reason to doubt an excellent to boot. Have you any actual experience of working alongside a Primary Care Nurse Practitioner?

    Let me relay my experience of a very recent visit to my local GP Practice. I was going for an over 40's man Health Check, following a PCT invitation letter. I'd asked by name to see my GP. The receptionist took the clinical decision over the phone that I should see a Practice Nurse assistant. When I arrived it turned out they'd ordered the wrong blood tests. I now have to attend another phlebotomy session followed by a further clinic visit. Three half work days lost due to their incompetence and I still don't get to see a real doctor. Though it is not a great loss; a normal visit to a GP is about 3 minutes long consultation with a disinterested locum. My expereince at Walk-In centres ahs been far better they are much more thorough.

  7. I've worked with nurse practitioners in primary care and dealt with referrals from them as well.

    Your GP practice sounds very poor indeed. I'd move.

    On the other hand, of course your WIC can afford to be more thorough - they have far greater resources.

    I have no doubt that WICs are a more pleasant experience for patients with shorter waiting times and longer consultation times. As a tax-payer I'd rather my money was spent on improving primary care as a whole rather than creating a more convenient experience for those that live near a WIC.

  8. I'm glad you accept my contention that WICs are a more pleasant experience for patients. Again look at the actual statistics and you'll find many of the WIC patients do not live close to the WIC, but they do find it is well positioned for their needs. In GP land the arrangements are designed to suit the needs of the GPs rather than the patients.

    The rest is down to accountacy quibbles. I contend that, taking into account overheads as well direct cost, per consulatation WICs are less expensive. We've already established the WIC nurses have tight clinical protocols to avoid straying outside of their brief.