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

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.

iStockphoto Photo's

We've occasionally used iStockphoto.com to provide photo's for presentations and advertising work. We've just received notice from them that they are "expiring" our credit because we've not used the account for a while. We regard that as theft. We don't care what their terms and conditions say, it is plain simple corporate theft. No doubt they'd take a dim view of anyone misusing the copyright material, but they have no problem with their own theft tactics.
If they do not want to continue to do business with us, they should just refund the outstanding credit.

They've now been added to our email blacklist and will no longer be recommended.

Political

I wonder why the South African Government is delaying the via of the Dali Lama? The Dali Lama is planning to visit Desmond Tutu in South Africa.  Some pressure from the DRC?

UK NHS reform GP cynicism

The Royal College of General Practitioners are complaining the proposed government reforms may unravel the National Health Service. The general "idea" is to give control of primary care funding to local consortia of GP's whole then commission services. At the same time the government are proposing to introduce competition for the provision of health services.

We must not lose sight of the fact that most General Practitioners are independent contractors/partners. The GPs do not have a contract of employment with the NHS. The GPs are allowed to keep the profits they make from the fees they charge government for the provision of health services. To allow the GPs to commission their own services represents a gross conflict of interest. Their primary motive is profit. The GPs already receive a massive annual income, as a private contractors, plus many hidden state subsidies. Giving them control of the purse strings is utter lunacy.

The Royal Collage of GPs complain that competition will wipe out the NHS [reduce the GP profit], yet at the same time GP commissioning groups actively campaign to halve the staffing levels of the existing NHS Walk-In Centres. These places are nurse led, using highly skilled medical practitioners, and provide a service 365 days a year from 7am through to 10pm. They handle 90% of the cases GP's handle and in many cases treat the overflow of patients who are unable to get an appointment at their own GP. Most GP practices are open to the public for about 8 hours a day for 250 days a year. The cost per clinical consultation is at the highly available Walk-In Centres is about 75% of an equivalent reduced availability GP consultation. The GPs hate the exposure that properly qualified Nurse Practitioners can provide a good clinical service without the need for expensive GP's.

A telling statistic is the consultation duration in a Walk-In Centre is an average of 12 minutes per person. These Nurse Practitioners are very thorough. Compare that with your own visit to a GP. most of their consultations last 2-3 minutes. The error rates at Walk-In Centres are very low, which is good considering the staff have to deal with unknown patients who walk through the doors.

One of those GPs looking for closure of the WICs is a close advisor of the Health Minister Andrew Lansley. Indeed Mr Lansley has introduced him at public speaking events as a GP expert. That same person is actively involved in the management of a local new GP consortia who will commission health services including the GP practices where the advisor has an ownership/profit interest. Their recommendation is to break up the WIC in his area (about 100,000 consultations a year). The WIC has already had substantial staff cuts imposed.

Not good. These ill consider government proposals have already caused a lot of damage and unnecessary expenditure. Prime Minister Cameron promised to protect the NHS yet he seems to have put it under the control of unreformed self-interest groups.

Why we stopped using Google Adwords

We used to use Google Adwords to advertise our business on the responses to Google searches by the public. We stopped using them. 

Why did we stop?

• It was not the cost;
• It was not the hit rate;

We stopped because we could not get to talk/online chat with a real person in Google about the problem we encountered. We had the wording of an advertisement rejected without explanation by Google. The advert wording was not offensive, nor so far as we could see did it breach any published Google rules. We were in fact trying to correct an entry generated by Google about our business. We keep getting calls from Joe Soap consumers asking us to fix problems with their home PC's. We don't do that. We build trading floors and data centres and we charge high fees for that specialist skill.

The only "assistance" from Google was an automatic  Catch-22 type of response referring us to the Google rules. We'd already checked those and needed to speak to a human being, but that appears to be impossible for Google. A typical response from a money rich global corporation who can afford to lose a percentage of customers through poor communication.

What triggered this blog posting? Google have emailed us an offer of £100 to start advertising with them again. The sender of the email - adwords-noreply@google.com!! Once again automated with no contact with a human being! What a waste.

Alaric


ps. I've just been told Google have sent a new email  to our director increasing their offer to £150. To think they could have avoided this if they'd decided to make it possible for us to actually chat to a human being.

PC Maintenance Department

I've just had one of those unsolicited calls from a bunch of crooks trying to convince me there is a virus infection on my PC. They were calling from an Indian sub-continent call centre over a very poor quality VOIP line. Their scam is to induce you to visit a webpage to check out your PC using their software. Typically your PC will become "Hijacked" until you pay some form on ransom to them to cure the problem they loaded on to your PC such as file encryption of all of your data & programs. Effectively your machine becomes unusable until you pay them. Even then there is no guarantee that your PC is left in a clean state.

Their pattern of operation is obvious:

1. A junior member of their team calls by phone and describes themselves as the PC maintenance group. They then feed you the line that your PC has reported faults and virus's to them. They'll suggest your machine is running slowly and erratically.
2. Next step is to get you to run a standard Microsoft tool already on the PC so you'll see routine status messages which occur (normally hidden) on every PC displayed on your screen.
3. The next step is to persuade you to visit their website to have it scan your PC to fix the "problem". If you do that you will cause a trojan program to load on to your PC and to commence it's evil work of corruption.
4. Then they'll tell you that you have to pay a "fee" to repair your PC.

I must tell you I hate these criminal parasites. I take every action possible to keep them talking on the phone (at their cost and time) while they try to persuade me to follow their instructions. I play the dumb user who makes loads of mistakes when entering their instructions. I don't tell them that I'm pretending my PC is running the old MSDOS 5 operating system which pre-dates Microsoft Windows. The result is that none of the PC commands they they tell me to use will ever work.  This time I had them talking for 45 minutes, with a chain of six of their "experts" before they gave up. 

Unfortunately they didn't call on a phone where I can record the conversation, but here's a typical extract from the conversation (remember I think I have a back and white character based display of MSDOS 5 whereas they think I have a standard Microsoft windows screen say - Vista.):

• criminals: "...Do you see the start button on your PC desk top?"
• Alaric: "No, I don't have a button on my desktop. It is just a standard office desk. There's the phone in one corner, a cup of tea in the other corner and my PC keyboard in front of me."
• criminals: "Just click the Start Button and type..."
• Alaric:"but I just told you I have no buttons on my desk top, it is just a desk. Ok I've pressed the button on the front of my PC and it turned itself off. Is that what you wanted me to do...?"

This went on for 45 minutes with them getting increasingly angry because I couldn't follow simple instructions. Eventually they gave up saying they'd call me back in a few minutes. Hopefully the time I spent on the phone reduced their ability to pester other people and cause real damage to those unsuspecting souls. Sadly with the British Telecom phone system it is nigh impossible to trace these criminals calling from overseas.