VOL: 98, ISSUE: 19, PAGE NO: 36
Elizabeth Anderson, MSc, BSc, RGN, is research associate, Division of Psychiatry, Bristol University. At the time of this research she was senior lecturer, Faculty of Health and Social Care, University of the West of England, Bristol;Catherine Pope, PhD, is lecturer in medical sociology, Department of Social Medicine, University of Bristol;Taj Manku-Scott, MSc, is research associate, Division of Primary Health Care, University of Bristol;Chris Salisbury, MD, MSc, is consultant senior lecturer in general practice, Division of Primary Health Care, University of BristolThe first NHS walk-in centre opened in January 2000, and there are now about 40 facilities providing drop-in nurse-led primary care in towns and cities across England. They were part of a package of primary care initiatives, introduced alongside schemes such as NHS Direct and Healthy Living Centres, which aimed to modernise the NHS.
The first NHS walk-in centre opened in January 2000, and there are now about 40 facilities providing drop-in nurse-led primary care in towns and cities across England. They were part of a package of primary care initiatives, introduced alongside schemes such as NHS Direct and Healthy Living Centres, which aimed to modernise the NHS.
Most walk-in centres are open seven days a week, from 7am to 10pm. This tallies with the idea that modern health services should respond to modern lifestyles, and that people should not be expected to take time off work to obtain health advice or simple treatments, nor should they wait days or weeks to see a health professional.
The idea is not new. In North America, Australia and South Africa, emergency centres, ambulatory care centres or urgent care centres provide similar, same-day access to health care (Hutchison, 2000). Many of these services are led by doctors, but in some centres nurses provide care equivalent to that offered by doctors.
A key feature of NHS walk-in centres is that they are all nurse-led: few employ doctors on site and most operate with a mix of nursing and support staff. Few other services are provided and directed by nurses without the significant involvement of GPs or hospital consultants, so these walk-in centres could represent a revolution for nurse-led care. Nevertheless, the research reported here suggests that there is considerable variation in the levels of professional autonomy exercised by nurses in the pilot walk-in centres.
NHS policy innovations are seldom the subject of rigorous piloting or independent assessment; initiatives are often rolled out without much thought as to how their success or failure might be judged. However, the pilot walk-in centres have been subjected to just such an independent national evaluation, conducted by a team of researchers from the University of Bristol.
A variety of research methods were used to gather information about the centres, including surveys of users and health care providers, and statistical analyses of national and local data on activity and costs. Descriptive information about the day-to-day running and work of the centres was collected during site visits, and through discussions with managers and staff. The research data collected raises a number of important issues for nurses.
What are NHS walk-in centres?
The pilot centres were established in response to a Department of Health tendering document, which specified core features for the services (see box). Despite this standard blueprint, the sites vary considerably in setting, size, and the services they provide (Salisbury et al, 2002). Most centres are located in town centres or residential areas, some are situated next door to hospitals or GP practices, while others are based in high-street 'shopfront' premises.
The size of the centres varies not only in terms of the physical space available, but also in the number of staff employed: this can be as few as six whole-time equivalents or as many as 14.
There is also considerable variation in grades and previous experience. Staff range from E to I-grade nurses who have previously worked as health visitors, practice nurses or in A&E. Some centres also employ health advisers, who provide additional services such as counselling, social services advice and health promotion.
The researchers found that the centres vary in terms of the health care they offer. Some appear to function like minor injury units, with the bulk of their workload being practical nursing care for minor trauma.
Centres with an A&E or minor injury unit next door may see more patients requiring advice and treatment for minor illnesses. Others concentrate on services targeting specific groups, for example particular ethnic or age groups, or on health promotion such as smoking cessation or healthy eating workshops. In most centres, nurses are able to supply some prescription-only medications from a specified list, usually guided by a patient group direction (PGD). However, the range of drugs they can supply varies from site to site.
Who uses them?
There has been a gradual but steady increase in the number of people using walk-in centres, with about 100,000 visits in July 2001. On average, each centre has about 80 visits a day, and each nurse consultation lasts around 17 minutes.
The impact on nurses
Walk-in centres have provided a unique opportunity for nurses to use their skills at the first point of contact with patients in primary care. Where else do they have the freedom to work autonomously without the day-to-day input of, or supervision by, doctors? Some patients may welcome the chance to see a nurse and spend time discussing their concerns. Indeed, our survey of users suggests that about 10% deliberately chose the centre because they wanted to see a nurse. Overall satisfaction with the service was high, at about 80%.
While nurses do not want to take on the role of mini doctors, a mantle frequently rejected as inconsistent with the nursing paradigm, nevertheless those working in walk-in centres examine patients and make treatment and prescribing decisions.
So does this represent a further blurring of professional boundaries between health care staff and greater autonomy for nurses? Our evaluation suggests that centres demonstrate variations on this theme. In some, senior nurses - grades F to I - undertake physical assessments, working at high levels of clinical decision-making, with the support of less independent D or E grades. In other centres, none of the nurses undertake physical assessments, so their function is much more akin to that of their counterparts in the telephone advice line NHS Direct.
If nurses are to extend their work beyond traditional boundaries, important issues regarding training must be addressed. We need to determine the level of knowledge and skills needed to underpin the role of walk-in centre nurses, and whether there are accredited courses to support learning to practise in these new environments. Some courses currently offer a range of relevant modules, for example in clinical assessment and pharmacology.
The evaluation suggests that induction and in-house training has not been uniform across centres, thereby limiting opportunities for professional development. Some of the nurses are already qualified nurse practitioners, so this type of training might be one of the ways forward. Although it would be foolhardy to reinvent the wheel, it is not clear what core training walk-in centre nurses require, given their disparate roles and the varying needs of patients attending the centres. Perhaps all walk-in centre nurses should receive core training against specified competencies, with senior grades holding relevant graduate or postgraduate qualifications.
As nurses enhance their roles, there is an increasing need to resolve these issues. Skill mix related to grade and based on clear educational and professional criteria could give nurses clear role boundaries, defined training needs and opportunities for career progression.
Walk-in centres can, and some do, offer opportunities for nurses to expand their skills and enhance the role they play in the modern NHS. Yet if the centres are simply the face-to-face counterpart of NHS Direct, the level of skill required is not what would be expected of an autonomous practitioner. There remains a lack of clarity about the purpose of walk-in centres that directly influences the role of nursing in today's NHS.
As well as the potential for autonomous practice, there is also the potential for nurses to retreat into task-oriented roles guided by decision-support software. We found some variation in the way nurses used this software. Those accustomed to making clinical decisions regarded it as an aid to managing each patient. They would sometimes override the algorithms if, in their professional judgement, this was warranted. But less experienced nurses might feel uncomfortable with this. All nurses have a duty of care to meet patients' needs within their level of competence (UKCC, 1992). The imposition of decision-support software to enable patient management does not sit comfortably with the evolution, in some walk-in centres, of nurses capable of managing complete episodes of care.
There was similar variation in the use of PGDs. While walk-in centre nurses cannot prescribe, they can supply medicines according to authorised PGDs. However, the number and format of PGDs varied enormously. Many nurses expressed frustration at the time taken to get them authorised and implemented, yet underlying this is the wider issue that these nurses are unable to prescribe. This represents another constraint on autonomous practice.
Feedback from walk-in centre nurses shows that they are optimistic about their progress and encouraged by the growing number of patients using their services. They are excited to be involved in the initiative and look forward to further challenges. Teething problems have been generally related to computer technology and the need to combat the negative attitudes of other local health professionals such as GPs. In most cases, these have been overcome by the sheer hard work and public relations skills of the nurses.
On balance, walk-in centres appear to offer new opportunities for nurses and the chance to challenge traditional ways of providing primary care. This is an opportunity not to be missed.
- Salisbury et al (2002) provide a medical account of the evaluation of NHS walk-in centres (see reference below)
- Turn over to p38 for GP Peter May's critique of nurse-led walk-in centres