Posted by: Jonathan Shapiro15 November 2013
Walk-in Centres were introduced in the late 1990s, largely for political (rather than health or epidemiological) reasons, and were originally staffed by nurses who could advise, but not prescribe.
At the time, the gossip had it that some bright spark in Downing Street noted that there were no GP practices around Parliament, and decided that it would be A Really Good Idea to introduce ‘General Practice Lite’ into the area so that MPs who were poorly could be treated without having to go all the way home…
Whether right or wrong in concept, the plan was an excellent example of how NOT to introduce change: there was no research done about the need for change, its impact, or its cost. And like most changes that have political origins, once made they are very difficult to undo.
In fact, like the Curate’s egg, they have been good in parts; where the standards of general practice were genuinely poor, the centres probably offered some alternative provision to offset this. However, more generally, their existence did not divert work from hospitals, nor did it do much to reduce demand on general practice itself; like so many NHS new ideas, it merely increased supply and so lowered the threshold of demand. Rather than working to increase people’s responsibility for their own healthcare (as is so often the rhetoric), increasing supply actually reduced it.
Moreover, a number of GPs started using the centres as outposts of their own practices, to get some of the more mundane manual treatments carried out at no cost or time penalty to themselves; minor procedures such as ear syringing and dressing changing could apparently be palmed off to the nurses at the Walk-in Centres.
And the whole shooting match was implemented without any apparent thought about the implications for the rest of the system; we’ve mentioned increasing supply without alleviating demand, but there were also issues concerning continuity of care, duplication of services (sexual health was a very common reason for attending Walk-in Centres, despite the fact that stand-alone sexual service centres often co-existed, sometimes in the same building), consistency of treatment, and the possibility of missing patients with complex problems presenting at a variety of unconnected venues.
A recent (but unpublished) review of the centres in one of our major cities confirmed that their absolute cost effectiveness (which admittedly does exclude patients’ feelings of security and wellbeing) was poor, and that their preservation should generally take a low priority when resources were tight and demand high.
The problem is how to close them without creating the kind of outcry we are already beginning to see? There is something about the NHS (especially when it involves buildings) that seems to bring out the territorial side of the British personality, and one of the unintended consequences of poorly thought out policy is its disentanglement without creating even more convoluted and ineffective sequelae. And it’s not just the noise factor; new demand has been created, and once the genie of public expectation is out of the bottle, it is very difficult to put it back.
Perhaps it would help if services were defined functionally rather than structurally, and their control left to one co-ordinating agency, without excessive political influence. If CCGs are genuinely to take responsibility for the health of their registered population, then letting them decide whether and how to provide services would allow the alignment of the power for its delivery with the accountability for its quality, cost and timeliness. Sure, there’d be some unpopular decisions to make, but separating these from an immediate political kneejerk reaction could only be helpful as long as the overall accountability was clear and inexorable.
Less political gesturing, clearer ‘broad brush’ accountability, and the room to produce practical solutions without having them stifled at birth; these seem to be recurring themes in all the current debates about public services.
Dr Jonathan Shapiro is a former GP with wide experience in clinical, managerial, and academic roles. He works with policy makers, organisations and individuals to develop effective, sustainable systems with integrated clinical and managerial functions You can email Dr Shapiro on firstname.lastname@example.org.