VOL: 98, ISSUE: 19, PAGE NO: 38
Peter May, MD, is a GP at The Grove Medical Practice, Shirley, SouthamptonPeter May, MD, is a GP at The Grove Medical Practice, Shirley, Southampton
Before I judge the work of the 'new arrival' on our local primary care patch, I feel it is best to set out some of my own core NHS values.
First, personal knowledge is essential to primary care. I know many of my patients very well, since I have treated some of them from infancy. I remember their relatives who died 20 years ago, I recall their crises and have documented their health history in my notes, referral letters and medical reports. Personal knowledge is essential to practising holistic medicine.
Closely related and second, is the gatekeeper role. Defensive medicine is a growing cancer in the NHS. A central point of access to the NHS safeguards the patient and is crucial to the economic viability of the NHS. We abandon it at our peril.
Third, I value teamwork. Nobody can claim to know it all. I work in a partnership of six GPs, plus a retainer-scheme GP and a registrar. We have four practice nurses and a phlebotomist. We work in a health centre alongside health visitors, school nurses, a counsellor and other health professionals. We consult one another throughout the day, and share information via an internal e-mail system.
Fourth, I value our cooperative, which has transformed out-of-hours care. It is the single best initiative I have seen in 22 years as a GP. Our co-op covers more than 80,000 patients: we have had hardly any complaints in its 2,500 days of operation and our patients greatly appreciate it.
So what do I make of the local walk-in centre? I think it is ill informed, duplicates services, and is isolated, inefficient, bureaucratic and expensive.
First, it is ill informed because the nurses do not have the most basic information. They do not know the patient, their past medical history or their current medication.
Second, it duplicates services: we have a duty doctor available every weekday from 7am until 7pm, when the co-op takes over. Requests for same-day appointments are triaged by a senior practice nurse, who often knows the patients and has immediate access to their records. She can give advice or direct them to her own clinic, the treatment room nurse, duty GP or make a non-urgent appointment.
Out of hours, our co-op doctor triages all calls, dealing with 85% of patients personally, either by phone or in the surgery. The remainder are visited by a deputising service. It is unnecessary to have a separate organisation providing a similar service half a mile away.
Third, the walk-in centre is isolated from the rest of the primary care team and relies on the use of computer protocols. Not only can the software be confounded by unusual presentations, but computers can never look at an ill patient - a second pair of eyes often saves the day. Many practices have lost good nurses to the walk-in centres. It is sad that highly competent staff are leaving the stimulating environment of a well-integrated primary care team to sit in front of a computer. It is a dumbing down of care.
Fourth, it is an inefficient operation. Our local centre is staffed by four or five nurses and sees about 70 patients in a 15-hour day, or about one patient per nurse an hour. The average consultation time is 15-20 minutes. What a luxury. If they can see everyone promptly, it is only because they are overstaffed. If usage increases, so will delays. In contrast, our co-op GP commonly deals with six patients an hour.
Nurses in this setting are a false economy. They have low productivity, long consultations, bring more patients back and make more referrals. On average, one in five patients is referred on (Salisbury et al, 2002).
Fifth, the centres generate bureaucracy. Every local GP now has to read faxed reports of trivia, which then has to be shredded, since it is not worth keeping. I had one report concerning a patient with a sore mouth that ran to three page. In contrast, hospital discharge letters may run to two lines. Patients might spend 30 minutes at a walk-in centre, only to be told to make a same-day appointment to see their GP. They may spend half a day obtaining help for a minor health matter that a GP could have resolved over the phone.
Finally, the centres are disgracefully expensive, costing an estimated £1m a year to run - and that excludes the enormous cost of setting them up (Department of Health, 1999). Sooner or later, the costs will fall on primary care trusts (PCTs). We could afford 40 practice nurses in Southampton for that amount - one for every practice in the city - to do a job that would be much more interesting and rewarding.
Walk-in centres should have been strangled at birth. Instead, they are becoming embedded in the system, with add-on clinics to justify their existence. It is the folly of an idealistic government, naively rushing in to save the NHS. But will the evidence ever persuade the prime minister to admit: 'They are a mistake. We will stop them'? Not a chance. Unless PCTs have the bottle to throttle them, the centres will divert valuable resources away from effective primary care.
- Next week the lead nurse at a walk-in centre defends the initiative