Woking and Weybridge NHS Walk-in Centres:

Local Evaluation 2000-2002

Dr Susan Turnbull

On behalf of the University of Surrey

Acknowledgements (1)Ross Lawrenson

John Roberts

Surrey Social and Market Research, University of Surrey: Rosemarie Simmons and Elaine Bowyer

WICLE Steering Group Graham Browning

Chris Dunstan

Lou Major

Sara McMullen

Iain McNeil

Vincent O’Neill

Stephen Price

Pauline Rogers

Cathy Winfield

Background: Local 39 Walk-in centres were set up as a pilot

project in 2000

£31 million funding, key role in governments’ NHS Modernisation Programme

Woking WIC opened April 2000

Weybridge WIC opened June 2000

Remit of WICs (1) Offer fast and convenient access to local

NHS advice, information and treatment

Complement, rather than compete with or replace local GP or hospital services

Open 7am-10pm weekdays; 9am –10pm weekends

Remit of WICs (2) No appointments

Treatment provided by experienced NHS nurses

Able to deal with minor injuries and illness, and encourage self-help

Allow GPs more time to deal with patients in need of medical expertise

Potential to relieve pressure on primary care/ decrease waiting times for GP appointments

Policy context – access to primary care

NHS Plan 2000:

“The public’s top concern about the NHS is waiting for treatment, including waiting to see a GP”

Target: by 2004 patients will be able to see a primary care professional within 24 hours and a GP within 48 hours

Policy context – access to primary care (2)

Practices would be “required to guarantee this level of access for their patients, either by providing the service themselves, entering into a relationship with another practice, or by the introduction of further NHS walk-in centres”

NHS Priorities and Planning Framework 2002/3

2 ‘must-do’s’ relevant to WIC aims:

Improving emergency services in terms of their availability, quality, comprehensiveness and speed

Reducing waiting throughout the system and in particular for consultations in primary care and hospital and admissions to hospital

PPF also emphasises need to address inequalities in access to services

Primary care access: pressures (Audit Commission 2002: General Practice in England)

1/3 of GPs and practice nurses >50

Increasing consumer expectations

Ageing population

Exacting national standards / quality/ monitoring

Greater scrutiny

Shifting of workload from secondary to primary care

More GPs part-time

Increasingly complex care

GPSIs – less time for ‘general’ practice

Other commitments outside the practice eg PCT

National Evaluation Commissioned as part of the WICs pilot

University of Bristol on behalf of the Department of Health

Published 2002

Each WIC submitted quarterly monitoring returns including activity and costings data

Local evaluations

DH funding to each WIC for local evaluation

Bournewood Community and Mental Health NHST managed both WICs: commissioned University of Surrey to evaluate both

Location

Study objective

To evaluate the impact of Woking and Weybridge NHS walk-in centres on improving access to health care

Combined quantitative and qualitative approach

Framework: Maxwell’s 6 dimensions of healthcare quality

Access

Equity

Effectiveness

Appropriateness

Acceptability

Efficiency

Quantitative analysis (1)

Database anonymised – year of birth and ward of residence only

Study period 9 October 2000 – 19 August 2001 – longest period when both WICs fully computerised + using same system (‘Interhealth’)

Quantitative analysis (2) ‘Initial visits’ rather than ‘all visits’ – to

avoid consideration of recurrent or review attendances for same condition

Initial visits :

24117 Woking

9020 Weybridge

Sex: WokingFemales 53.2%

Sex: WeybridgeFemales: 55.8%

Visits by age and sex

0

5

10

15

20

25

30

35

0 to4

5 to14

15 to24

25 to44

45 to64

65 to74

75 to84

85andover

Age group

% o

f vi

sits Female Wok

Male Wok

Female Wey

Male Wey

Comparison of Age Bands of local population and WI C visitors

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%

Age Bands

Woking Borough age breakdown North Surrey Boroughs age breakdown

Woking % visits by age band Weybridge % visits by age band

Time: trends in visit numbers

0

500

1000

1500

2000

2500

3000

3500

Nov-00

Dec-00

Jan-01

Feb-01

Mar-01

Apr-01

May-01

Jun-01

Jul-01

Nu

mb

er o

f vi

sits

Wok

Wey

Proportion of visits by day attended

02468

101214161820

Mon

day

Tues

day

Wed

nesd

ay

Thurs

day

Friday

Satur

day

Sunda

y

Day of week

% o

f vi

sits Female Wok

Male Wok

Female Wey

Male Wey

Time of day: weekday vs. weekend

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

Time attended

% o

f v

isit

s

Weekday

Weekend

Time attended, location and sex

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

Time attended

% o

f v

isit

s Female Wok

Male Wok

Female Wey

Male Wey

Ward of residence Most visits from residents of closest wards

Woking: Visits equivalent over a ¼ of these wards: Kingfield & Westfield (33.7%) Mount Hermon West (31.7%) Mount Hermon East (28.8%) Old Woking (28.3%)

Weybridge: Weybridge North (27.7%) St George’s Hill (27.1%)

Woking WIC

Ward- based visit frequency with increasing Townsend deprivation score

-6

-4

-2

0

2

4

6

8

Ward

Town

send

Dep

rivat

ion

Scor

e

0%

5%

10%

15%

20%

25%

30%

35%

40%

Freq

uenc

y as

% w

ard

popu

latio

n

Townsend Score

Freq as % ward pop

Woking WIC

Townsend deprivation score with increasing ward- based visit frequency

-6

-4

-2

0

2

4

6

8

ward

Town

send

Dep

rivat

ion

scor

e

0%

5%

10%

15%

20%

25%

30%

35%

40%

Freq

uenc

y as

% w

ard

popu

latio

n

Townsend Score

Freq as % ward pop

Weybridge WIC Ward-based visit frequency with increasing Townsend deprivation score

-5

-4

-3

-2

-1

0

1

2

St.G

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Tow nsend Score

Freq as % w ard pop

Weybridge WIC Ward-based visit frequency with increasing Townsend deprivation score

-5

-4

-3

-2

-1

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St.G

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Freq

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popu

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Tow nsend Score

Freq as % w ard pop

Weybridge WIC Townsend deprivation score with increasing ward-based visit frequency

-5

-4

-3

-2

-1

0

1

2

She

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Tow

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St.A

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0%

5%

10%

15%

20%

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Freq

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Tow nsend Score

Freq as % w ard pop

Woking: Visits as % of practice list size - top 16 GPs

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

45.0

SMIT

H PJR

HENDRY AE

LYTTON G

J

POO

L RJ

MELLO

R JP

KEMP O

BOURKE M

J

SHAH AH

CLOSE A

R

PANHWAR G

M

YUSUF IA

CROSSLEY J

N

SHEPHEARD AC

LAWRENCE R

S

CAMERO

N EG

M

BATES PC

Pe

rce

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Woking: Visits as % of practice list size - top 16 GPs

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

45.0

Per

cen

tag

e

Weybridge: Visits as % of practice list size - top 12 GP practices

0

5

10

15

20

25

STEDMAN A

E

DE SO

USA EAJ

STEEL CN

DELAIMY L

J

ARNOLD P

F

MEECHAN P

O

NOO

N CC

CROSSLEY J

N

RATCLIFFE D

M

SHEPHEARD AC

BATES CC

LAWRENCE R

S

Pe

rce

nta

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Weybridge: Visits as % of practice list size - top 12 GP practices

0

5

10

15

20

25

Per

cen

tag

e

Access and equity Gender pattern of attendance similar to general practice F>M.

Opposite re A&E M>F

25-44 year olds most frequent attenders – but also largest age group

Older people attending in numbers appropriate to population

proportion (Woking – even higher)

Most WIC visits not ‘out of hours’

Visits gradually increased

Highest proportion of visitors live nearby and/or are registered with GP practice close to WIC

Proportion of visits by diagnosis (1)

0

5

10

15

20

25

30

35

40

Diagnosis (1)

% o

f vi

sits Wok fem

Wok male

Wey fem

Wey male

Proportion of visits by treatment (1)

0.05.0

10.015.020.025.030.035.040.045.0

Treatment (1)

% o

f vi

sits Wok fem

Wok male

Wey fem

Wey male

Proportion of visits by discharge recommendation

05

101520253035404550

Discharge (1)

% o

f vi

sits Wok fem

Wok male

Wey fem

Wey male

AppropriatenessDisappointing proportion of missing data

Commonest diagnoses: Soft tissue injury Woking; ENT Weybridge

Commonest treatment: advice and reassurance

Woking: 83.5% with A&R as treatment (1) had no treatment (2) recorded. Weybridge: 90.1%

Effectiveness

Estimates of impact based on visitors reported ‘alternative’ in the absence of a WIC

Caution about ‘desirable’ responses – ? bias against ‘self-care’ as ‘alternative’ to justify decision to seek professional advice

Proportion of visits by ‘alternative’ if no WIC available

05

1015202530354045

Alternative if no WIC

% o

f vi

sits Wok fem

Wok male

Wey fem

Wey male

‘Alternative’ Disappointing proportion of missing data

Very small proportion where alternative = self care, especially Woking

Woking males – almost equal re GP and A&E

Weybridge females: >3x as many GP as A&E ‘alternative’

GP ‘alternative’ most frequent both WICs

‘Alternative’ = GP by ‘discharge’

0

10

20

30

40

50

60

Discharge (1)

% o

f vi

sits

Woking

Weybridge

‘Alternative’=A&E by ‘discharge’

05

101520253035404550

Discharge (1)

% o

f vi

sits

Woking

Weybridge

‘Alternative’= self care by ‘discharge’

010

2030

4050

6070

80

Discharge (1)

% o

f vi

sits

Woking

Weybridge

Acceptability Quantitative analysis did not address

acceptability

Growing attendance suggests acceptability

User survey at Woking WIC July 2000:(Rogers,P. Case study of one walk-in centre pilot site. University of Surrey. Dissertation for MSc in Health Care Management)

•EfficiencyQualitative study did not address

efficiency

Cost per visit calculated using same criteria as national evaluation: all running costs (no set up costs); all visits

Efficiency (2)

Woking: Running costs quarter

ended 31/03/01: £ 159k

Estimated ‘all visits’: 8353

Estimated cost per visit

£19

Weybridge: Running costs quarter

ended 31/03/01: £156k

Estimated ‘all visits’: 2644

Estimated cost per visit

£59

Efficiency (3) Higher cost per visit Weybridge: similar running

costs, visit rate much lower in study period

Recent enquiry: Weybridge activity increased by > 3-fold. Cost per visit for Oct 2001 – Aug 2002: £15.36

Reinforces ‘moving picture’

National evaluation – comparable cost per visit £31.11

Average cost of visit to a GP £15; practice nurse £9

Qualitative study (1) Surrey Social and Market Research (SSMR),

Department of Sociology, UniS

Aim – assess impact on other local health services providers: GPs, receptionists, practice nurses) GPs re OOH perspective Staff of nearest A&E Surrey Ambulance Service personnel WIC personnel

Total 30 interviews January 2002

Qualitative study: access & equity Access probably be limited by distance

Use may be limited by lack of awareness

Need for publicity: services provided, and exclusions

WICs probably unpopular with older people

Noticeable use of Woking WIC by Woking Asian community (largest in Surrey)

Qualitative study: appropriateness Most agreed WICs dealt with appropriate minor conditions

GPs felt WIC staff erred on side of caution

Some A&E, WIC and ambulance staff considered WIC eligibility criteria too rigid

WIC staff keen to have feedback on how they are doing

WIC staff – the presence of the WIC may be encouraging some unnecessary visits

A GP: “it may muddy the distinction between what is an emergency and what can wait

Qualitative study: effectiveness GPs had noticed little if any impact on workload

Most GPs felt referrals to them from the WICs were appropriate

Main impact on A&E department staff was loss of experienced colleagues

Most considered WICs had not generated new work for others

Qualitative study: acceptability GPs: expectations mixed but experiences generally favourable

Most felt patients confident about advice from WIC

Very positive feedback from some patients

WIC staff: conflict generated by ‘walk-in’ name implying no/minimum waiting

Ambulance staff: noted patients preferred faster WIC turnaround times cf. A&E. Better if WICs open 24 hours – patient refused after 9pm re 10 pm closure

Summary: key points – quantitative (1)

Main determinant of WIC use is proximity to home, or GP practice where registered

Apparent correlation between increasing visits to Woking WIC, and Townsend deprivation category

Most visitors: Were managed in the WIC and discharged home Received only ‘advice and reassurance’

‘GP’ was the most frequently reported ‘alternative’

Summary: key points – quantitative (2)

WICs appear to have diverted substantial numbers away from original intention – estimated 874/ month from GPs

GPs whose practices are closest appear to have benefited most.

No evidence of WIC-generated extra demand for GP or A&E attention

Woking WIC inclined to review more in WIC; Weybridge referred higher proportion to own GP

National Evaluation of NHS WICs (Salisbury,C. et. al, University of Bristol, July 2002)

Access improved for young and middle aged men who are relatively low GP users

WIC users more likely to be young adult, white owner-occupiers educated beyond age 18

This may increase health inequalities

Users highly satisfied

Low rate of referrals elsewhere suggests most WIC consultations were appropriate

National evaluation (2) Impact of a WIC a drop in the ocean re number of

consultations compared with GPs/A&E nearby

Possible total NHS workload may have increased as result of the WIC initiative

Little evidence of duplication of care

Cost per visit higher (£31 average) than GP consultation (£15)

Safe, quality care but at extra cost

Benefits and costs must be weighed against competing claims for NHS resources

Comparison and Conclusions

Aggregated national analysis is not informative about local variations

National evaluation did not use deprivation indices

Local evaluation shows key determinant of WIC is proximity of home, or GP practice where registered

Potential to address health inequalities - targeted, strategic siting of WICs near populations whose needs are greatest

Conclusions

Woking cost per visit at time of evaluation compared well with national average, and GP cost

Weybridge didn’t – but does now

Stresses moving picture and importance of avoiding a rush to judgement

But when visitor numbers treble – increased waiting, less accessibility/ acceptability, possibly reduced effectiveness working under pressure

Trade-off between Maxwell’s dimensions

Unanswered questions Could WICs be generating new, previously

unexpressed demand?

How much duplication is there?

How much are WICs promoting self-care, or inadvertently encouraging the ‘worried well’ to seek professional advice?

How can the impact of WICs on demand for other services be disentangled from those of NHS Direct

Future developments Keeping the NHS local: A new direction of travel

(DH January 2003)

“Ambulatory care plus” - “models of care that build on existing primary and community services, such as walk-in centres, advanced access surgeries and community hospitals”.

Similar to US Kaiser Permanente approach to primary care:

large team including specialist/ generalist doctors; physician assistants and nurse practitioners with own lists

Facilities open evenings and weekends.

On site labs, x-ray, pharmacy………………………..