Tuesday, 22 November 2011

More about NHS WICs

My blog piece on NHS Walk-In Centres has generated some interesting, if uninformed, comment so I’ll extend the article somewhat.
The idea of the Walk-In service is that patients can walk in from the street if they want medical advice, after treatment the patient walks out. The Walk-In Centre does not deal with A&E cases, though it is not unknown for ambulance crews to deliver patients to a Walk-In Centre where the condition is minor. The general rule is that if the patient has broken bones, needs a stretcher or has chest pains they get directed to A&E.
The WIC consultation is designed to be a one shot process. To assess and treat if appropriate; the WIC procedures are not designed for follow up sessions. If follow up is necessary the patient will be referred back to their own GP or to acute medical practitioners in an appropriate local hospital. The WIC may offer associated services such as a phlebotomy clinic (taking bloods), but not as part of their routine assessment process.
Mostly the cases for assessment and treatment are where the patient presents with headache, high temperature, colds and flu.  They are cases that would otherwise clog the waiting areas of the local GP or A&E Department. The WIC normally has a qualified medical prescriber present during their open hours, the usual route for patients to obtain medicines is to visit a local pharmacy, but the WIC will also hold a stock of common medicines for on-site dispensing.  When the WIC practitioner recognises a serious underlying condition the person will be referred back to their GP or in urgent cases on to the local A&E department. These referrals routinely represent a very small proportion of the cases handled.
The Walk-In Centre is normally led by a senior primary care nurse practitioner (Matron).  The lead nurse will usually manage both nurses and administration staff. Where appropriate the lead nurse /Matron will also employ a part time salaried GP to handle cases that need the skills of a GP but patient cannot for some reason attend their own GP. Most primary care nurse practitioners (PCNP) are qualified to MA degree level in an appropriate medical discipline with additional training specifically to work as a Nurse Practitioner. They will usually have at least 10 years experience of actual practice in the primary care area. They are decidedly not “Practice Nurses.”
The nurses in the walk-in centre are trained in medical assessment. They are expected to take comprehensive notes recording how they reached a diagnosis in each case. Those records are personally signed as a legal record by the nurse. The WIC matron regularly audits the patient records for quality for the nurses and the salaried GPs. Nurses are provided with detailed written rules as to how to perform their work. They are not permitted to perform such work unsupervised until they’ve been given a written sign off of their competency. They are also encouraged to routinely consult with their seniors when they have any uncertainty. A recent study in the litigious USA showed that less than 2% of Nurse Practitioners were mentioned in medical claims. In the UK the training and supervision is more intensive.
The concept of the UK NHS Walk-In Centre was created in the late 1990s by the Labour Government. It was a time when the public in some locations found it notoriously difficult to obtain a consultation at their GP’s surgery. GP surgery hours were limited and normal working people would have to take time off work for a 3 minute consultation with their local doctor when they finally achieved the minor miracle of getting through to the GP receptionist phone. Most GPs are not directly employed by the NHS, they act as sole practitioners or partnerships that have few actual constraints on how they deal with patients or which actual hours they are available to patients. GPs will contract with a local primary care trust to provide services, but it remains the fact that GPs are their own bosses.  The design of the Walk-In Centre service was to counteract that lack of service. WICs were specified to be open daily (364 days a year) from 0700 through to 2200 and thus not just constrained to working hours.
In the past few years WICs close to acute hospitals have been performing an additional function in reducing the waiting queues at the A&E departments. A skilled nurse(s) from the WIC would be stationed in the local A&E department adjacent to the waiting area to perform first line triage of attending patients. Those with minor conditions are advised (not mandatory) to visit the near-by Walk-In Centre to receive quicker appropriate treatment


  1. Now I like a good debate but if you're referring to me as uninformed then you're making yourself look more than a little foolish.

    The problem with WICs is that they fulfill a want and not a need. People want their routine healthcare immediately and as conveniently as possible. They expect the supermarket open all hours service when in fact healthcare should be likened to a solicitor or accountant. I don't hear people complaining about having to take time off work because their solicitor doesn't open after 6pm or because their accountant won't see them on a Sunday.

    If you have an urgent medical problem there are facilities to care for you. If you have something non-urgent there are facilities for this as well. The only advantage of a WIC is that it provides these things almost immediately and on demand. This is expensive - both by comparison to A+E or GP and also because of the duplication in services and lower skillset of the staff employed.

    So I am not at all surprised that people enjoy the service provided by WICs with their short waiting times and long consultation times.

    The problem is that, as professionals, our job is to provide the best possible service with the resources we are given. Very simply, WICs do not provide value for money to the NHS. If you are able to point me towards some evidence to the contrary I'd be glad to read it.

    Best wishes

  2. I like a good debate too, indeed this is something sadly lacking in the closures of WICs. I'm happy with the concept of GPs being paid no more than £56 per patient per year, provided they are accessible 365 days a year between the hours 0700 - 2200 and to also cover the cost of building rental, utilities, security, practice nurses, practice management and administration.
    Of course in my case it would mean the NHS has paid my GP £466 per consultation on my behalf excluding the additional ones caused by GP practice errors.
    The cost differential between GP, WIC and A&E was in a printed journal a couple of years ago. I've retained the figures but not the paper. No doubt the Dept of Health has it available and calculated on a like for like basis.

  3. Just to be clear - you think that for £56 per year (that's less than £5 per month) a patient should be entitled to be seen as many times as they like at a surgery which is open every day of the year from 07:00 - 22:00. Most people pay 3 or 4 times that per month for a broadband subscription.

    The idea is ludicrous. The number of doctors required to staff such a practice would mean that they'd be paid less than minimum wage.

    I only know of the situation in Nottingham but there was a public consultation. 1500 people got involved. The most favoured option was to incorporate the WIC funding into primary care streaming in A+E.

    There are reams of documents available here

    These are the costs per contact according to their research:
    WIC £40 (in hours and weekends)
    Primary care stream at ED £21-31 (in hours and weekends)
    GP out of hours service £32-55 (in hours and out-of-hours)

    There is no data for cost per contact at the patient's usual GP but it will be significantly lower than £20.

  4. Let's just say the costs I've seen charged to the Primary Care Trusts by out of hours services and A&E Departments in actual billing are rather different. The case becomes much worse for A&E Departments when a PFI Hospital is involved.

    It would be interesting to see the Notts figures properly challenged by a forensic accountant with access to actual data. For example it is not unusual an GP providing contract out of hours cover to be paid in excess of £80 an hour, then add the cost of a admin staff, driver etc etc