The rise of the walk-in centre

18 August, 2008 | By Jennifer Taylor

In less than a decade walk-in centres have become a vital part of NHS service provision. Jennifer Taylor looks at the future of these ventures and the nurses who work in them

The walk-in centre model was launched by the Department of Health in 1999, with the aim of providing the public with more convenient access to NHS services. Latest estimates suggest that there are now more than 90 such centres throughout England.

The 43 original walk-in pilot sites were established between January 2000 and February 2004. These were followed by 29 centres and then a third wave of six NHS commuter centres, located close to railway stations and run by the independent sector.

Walk-in centres offer ready access to treatment and advice for minor illnesses and injuries without requiring registration or appointments. Their remit includes minor infections and rashes, fractures and lacerations, emergency contraception, stomach upsets, superficial cuts and bruises, minor burns and strains. Some centres have access to GPs.

NHS walk-in centres see around three million patients per year. On average, they see around 120 patients a day, although this figure varies significantly depending on location and opening times. Some sites see as many as 200 patients daily.

So what has been the public and professional reaction to the creation of these centres and just what impact have they had?

And what opportunities are they offering nurses?

Mandy Bullough is clinical nurse manager at Leigh NHS Walk-in Centre in Lancashire. Leigh Infirmary’s A&E department became a minor injury unit in 1995 and, in 2000, a walk-in centre.

According to Ms Bullough, patients who were ‘very, very upset’ by the loss of an A&E unit have come to really appreciate
the walk-in service in Leigh and it is well used, with around 53,000 patients visiting each year. Its phlebotomy service, which runs from 7am–10am Monday to Friday, is extremely popular. People can now drop in on their way to work, whereas previously they had to take the day off to access the hospital’s 9am–5pm service.

Leigh also runs three sexual health clinics a week, where nurses provide contraception including implants, and carry out smear tests and chlamydia screening. Young people appear to prefer attending the walk-in centre for sexual matters as it offers them more anonymity.

‘It’s not like a family planning clinic where you might see your mum’s friend or you might see your mum,’ explains Ms Bullough.

‘The young people really like to come to us because they can sit in the waiting room and nobody really knows why they’re there.’

While being on a hospital site has advantages and means the nurses can request X-rays, the location also has its downsides.

For example, patients with chest pain come straight to the walk-in centre. The nurses then have to call ambulances for patients who need to be taken to the nearest A&E. ‘I think it’s just in panic people come to the hospital,’ says Ms Bullough.

Lindsey Kelly is clinical lead nurse at Manchester’s Wythenshawe Forum NHS Walk-in Centre. She says that despite initial scepticism among some GPs, they are now routinely referring patients to the centre for blood samples, blood pressure checks and dressings.

However, Ms Kelly points out that there are also drawbacks, with many patients using the centre because they cannot
book appointments with their GP. ‘They’ve got this ludicrous system where [patients] have got to ring up on the day. [GP receptionists] say: “We’ve no appointments, go to the walk-in centre”,’ she says. It may not be appropriate for many of these patients to visit the walk-in centre as it does not cater for long-term conditions, she adds.

Newham NHS Walk-in Centre in London is based on the Newham General Hospital site. Daniel Apau, clinical lead, says that the centre has been a great success, with patients enjoying its easy access.

Again, however, there is a problem with inappropriate presentations. Some patients have visited their GP and come to the walk-in centre for a second opinion, Mr Apau explains. Others should have gone to a specialist or to A&E, and some come in asking for paracetamol.

‘There are times when you feel people are not using the right service at the right time and people are abusing the system,’ he says. However, as a nurse practitioner, Mr Apau finds the work satisfying, and says it is rewarding knowing that you can make a difference to how patients access their healthcare.

In many ways walk-in centres offer nurses more responsibility and autonomy than other areas of the profession. Training and development is an important part of every centre and nurses acquire skills to enhance their practice. Mr Apau, for example, has become an independent prescriber and has learnt minor surgical procedures for incision and drainage, and suturing.

Stephanie Goodall, practice development nurse at Nottingham NHS Walk-in Centre, agrees that walk-in centres offer unique career opportunities for nurses. Nottingham’s centre, which opened in 2000 in the heart of the city, now sees around 60,000 patients a year, treating 85–90% of these.

‘I think it’s an excellent place for nurses to expand their roles,’ says Ms Goodall.

‘A lot of our nurses are seeing, diagnosing and treating. When nurses work here, they get a vast amount of experience that then will allow them to move on to a more advanced practitioner [role] because they’re getting a wide variety of conditions walking through the door,’ she adds.

The centre aims to have all of its nurses achieve degree-level qualifications, and to increase the numbers attending advanced practitioner courses. It also aims to increase the number of nurse prescribers.

Nurses at walk-in centres agree that working autonomously is central to their role and it is this that sets it apart from many other nursing jobs.

‘You haven’t got doctors around – you’ve got to make the decisions,’ Ms Goodall says. But she points out that this doesn’t suit eveyone. ‘In the past I think we’ve had a couple that left because they just couldn’t cope with not being able to call a doctor to see [the patient],’ she says.

Ms Bullough agrees that it can be quite difficult to make clinical decisions without the support from other colleagues. ‘[As a nurse] you usually follow instructions a lot more where you’ve got people to back you up. Whereas I think the hardest part of the job is making those decisions. That’s quite difficult because you worry.’

Nurses may also find working in a walk-in centre more mentally challenging. ‘When you first come into it and you’re sitting in a room and you’re seeing these patients and giving them advice on your own, it is quite mentally demanding. You’ve got to think
on your feet [about] the advice you give,’ says Ms Kelly.

Walk-in centre nursing has similarities to other nursing roles. Ms Kelly says it can be compared with working in A&E. ‘We don’t know what’s coming in the door, we don’t know the demand – is it going to be busy, is it going to be quiet?’, she says.

So where does the walk-in centre sit in future plans for the NHS? Those in existence are already changing, albeit to varying degrees.

How walk-in centres evolved in the NHS

1999: NHS walk-in centre model launched by the Department of Health in order to provide accessible healthcare to match modern lifestyles
2000–2004: 43 walk-in centre pilot sites established
2004: Second wave of 29 walk-in centres opened, offering similar services but some housing GPs
2005: Third wave of six NHS commuter walk-in centres opened, located close to railway stations and run by the independent sector
2008: More than 90 NHS walk-in centres in existence across England

Nottingham looks set to stay in the same location but to increase its clinics. Leigh looks likely to employ more nurse prescribers, expand its sexual health clinics and possibly move into new purpose-built premises, which could also house a GP practice and district nurses all on the hospital site. In south Manchester Ms Kelly oversees three walk-in centres, one of which is based at Withington Community Hospital, which she can see becoming an urgent care centre.

Becoming urgent care centres is a possibility for walk-in centres in London, following junior health minister Lord Ara Darzi’s review of the capital’s healthcare. His Framework for Action report, published in July last year, suggests that all polyclinics will house urgent care centres and that local hospitals will have centres that are open 24/7, which will act as a ‘front door’ to A&E and operate in a network of care with a major acute hospital.

However, the DH says the shift is not inevitable. ‘Decisions on turning walk-in centres into urgent care centres are local matters made by PCTs who are best placed to understand and commission services that best reflect local needs,’ a spokesperson said.

Newham NHS walk-in centre has already piloted being an urgent care centre. For a weekend the service operated within A&E and every patient had to speak to the walk-in centre’s ‘nurse navigator’. Results showed that 45% of patients had been diverted to the walk-in centre.

Mr Apau says that he would welcome a move to enhance the scope of practice in order to include diagnostics and X-rays plus extend hours. Longer hours are needed because the centre has exceeded its projected capacity for patients.

Ms Bullough is also positive about the future. ‘I think you’ve got to just move with the times and what’s needed,’ she says. ‘It’s the crème de la crème of jobs because you’re doing what you trained to do which is to see, diagnose and treat people.’

The feature on community foundation trusts will be published on 2 September

‘For anybody it would be a good career move’

Sheila Clarkson joined Leigh NHS Walk-in Centre when it was just starting up and is now a sister and lead on sexual health. She had previously worked in A&E.

‘I worked a few shifts when I was on maternity leave and it was just a revelation how much the nurses were able to do. In A&E we were getting someone in and getting them ready for the doctor to do the procedure whereas [at the walk-in centre] the nurses were actually doing the complete episode of care themselves. It was that whole move into the autonomous role.’

The site at Leigh Infirmary had originally been an A&E department. Becoming a walk-in centre opened its doors to primary healthcare problems.

A lot of training was provided at the outset by a local GP, since many of the nurses were from an A&E background. They learnt about examinations and diagnostics for primary care problems.

Ms Clarkson had not worked in sexual health before. Demands for the service have increased and she has now done a BSc in sexual and reproductive health at the University of Central Lancashire.

Most of Ms Clarkson’s time is spent on sexual health, which includes clinics at the walk-in centre plus an outreach programme into massage parlours for hepatitis B and cytology.

In terms of work-life balance, Ms Clarkson says: ‘I think it compares favourably because of not having to do nights. That was something that I personally found stressful.’

She recalls that working nights permanently was not so bad but rotating between days and nights was really difficult. ‘Because we close in the evenings you don’t get that form of stress,’ she says.

One downside is the rise in pressure when the centre is short staffed. ‘You’ve still got the same numbers coming through the door and fewer of you to deal with them. It is just that the whole recruitment process has become much longer with CRB (Criminal Records Bureau) checks and getting posts through banding. It’s a lot harder than it used to be to get people in post.’

However, even during those pressure periods, the job is still very rewarding, she insists. ‘I think for anybody it would certainly be a good career move,’ she says. ‘The experience and skills you gain can transfer into management settings or specialist nurse settings.’