Woking and weybridge nhs walk in centres local evaluation 2000 2002
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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. Graham Browning

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Woking and Weybridge NHS Walk-in Centres: Local Evaluation 2000-2002

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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


Graham Browning

Chris Dunstan

Lou Major

Sara McMullen

Iain McNeil

Vincent O’Neill

Stephen Price

Pauline Rogers

Cathy Winfield

WICLE Steering Group


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


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

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


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


Access

Equity

Effectiveness

Appropriateness

Acceptability

Efficiency

Framework: Maxwell’s 6 dimensions of healthcare quality


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


Time: trends in visit numbers


Proportion of visits by day attended


Time of day: weekday vs. weekend


Time attended, location and sex


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%)


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)


Proportion of visits by treatment (1)


Proportion of visits by discharge recommendation


Appropriateness

  • Disappointing 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


‘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’


‘Alternative’=A&E by ‘discharge’


‘Alternative’= self care by ‘discharge’


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)


Efficiency

  • Qualitative study did not address efficiency

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


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 (2)


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………………………..


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