joint appointments

NHS walk-in centres are part of the Labour government's attempt to remodel the NHS into a fast and convenient service where care is delivered to a consistently high standard. The centres offer fast access to health advice and treatment, seven days a week. They are open without appointment and provide core services, which include assessment by an experienced NHS nurse, treatment for minor injuries and illnesses and instant access to health advice and information.

Health circular HSC 1999/116 invited pilot applications for walk-in centres. To be successful, pilots had to include a staff-mix to maximise the skills and experience of nurses, establish links with patients' own surgeries (to ensure continuity of care) and provide a walk-in, immediate service.

Applications were solicited for a mix of servicedelivery configurations, including co-location with accident and emergency and high street positioning.

Since opening, walk-in centres have faced a barrage of public criticism. Earlier this year, consumer magazine Which? sent three researchers, posing as patients, to eight walk-in centres.

1They found that the level of care varied greatly. Doctors asked by the magazine to evaluate the researchers' experience, highlighted examples of excellent care and advice, but felt that the overall standard was disappointing.

Old Swan walk-in centre in Liverpool opened its doors on 5 April 2000. It is housed in a two-storey health centre built in the 1980s. It comprises a waiting room with seating for 14, a triage bay, a reception area, four treatment rooms and a small staff kitchen. It is staffed by two project managers, both on fixed-term contracts, a clinical lead, 10 nurses who are G, F and E grades, a health support worker, a phlebotomist, a cleaner and four administration and clerical staff. The centre is open 7am-10pm Monday to Friday and 9am-10pm weekends and bank holidays.

The centre operates an autonomous nurse-led service with links to local practices, GP out-ofhours services, community trust services, emergency dental services and NHS Direct. All staff are encouraged to work in extended roles.

The role of a walk-in centre is 'to act as a triage point supporting existing primary care services, provide a service where there are currently gaps in provision and offer a convenient service to patients'.

2With this in mind, all patients attending the centre are registered by clerical staff and assessed by a nurse.

Where possible, nurses manage and treat the patient in a completed episode of clinical care. If the patient needs medical intervention, contact is made with their GP and usually an urgent appointment is made. If their GP is not available, the walk-in centre has service-level agreements with a local GP practice and the GP out-of-hours co-operative which provide urgent medical support. Where a patient needs another form of intervention, fasttrack referral protocols transfer them to other service providers, such as A&E, social services or specialist response teams.

About half of the patients attend for routine procedures, such taking blood samples, while many of the remainder have complex, multi-pathology complaints. The nurses work to strict assessment and treatment protocols drawn up by a working group of medical, nursing and pharmaceutical specialists. Of the patients attending the centre, 57 per cent are discharged without having to be referred elsewhere.

The centre saw 28,000 patients in its first year. It is now seeing more than 3,000 patients a month. A service has been provided every day, including Christmas and new year's day when the co-location of the GP out-of-hours clinic at the walk-in centre ensured as many patients as clinically feasible had a complete episode of care.

The nurses in the centre come from a variety of backgrounds, including A&E, practice nursing and district nursing. The community nurses initially showed greater confidence in working autonomously, while those with a background in A&E coped best with the emergencies and traumas at the centre - despite its advertisement as a minor injuries service. All nurses have been given a training assessment package to develop their particular skills.

The centre's management team, consisting of a project manager, nurse manager and project assistant, has worked hard to cultivate relationships with local GPs. This has been challenging. Initially there was resentment among primary care staff that investment went to a pilot project rather than into an established means of provision. But we now have good working relationships with most local GPs.

Hostility has been limited to a few difficult questions at public meetings.

The centre aims to be an access point for patients where they can be directed to other services as necessary. Consquently, a lot of time has been invested in developing referral procedures with other NHS and non-NHS providers. Building up and maintaining a database of contacts in and outof-hours is time-consuming but well worthwhile.

The centre is guided by a steering group, comprising representatives from the community trust, primary care group, health authority, social services, community health council, local medical committee, GP co-op and A&E departments. This collaboration has been fundamental in developing coherent working arrangements that complement existing provision and ensure that those patients most disadvantaged through access barriers benefit above all.

There are challenges in managing patient demand. Although the centre is open from 7am, many patients still arrive at 9am as this what people are used to in primary care. It is difficult to manage patient demand when advertised as a noappointment, no-wait service. But the large peaks and troughs in attendance we had in the early days have flattened as attendance has increased. In April 2000 there were fewer than 1,500 attendances. Now the centre sees some 3,600 patients a month.

Patient expectations also create difficulties. The centre is close to the site of the A&E department at Broadgreen Hospital, whose closure provoked acrimony in the 1990s. Many local people see the centre as the A&E department reincarnated, and attend with acute illness. It is the centre's job to deal with the patient as quickly and appropriately as possible, and not to chastise them for misusing the service.

Another issue is the maintenance of the centre's corporate image in the face of scrutiny and inspection from all sides. We are corporate services, but we need to develop some sense of independence to meet the specific needs of our local population.

The Department of Health has been very keen to promote walk-in centres as a corporate service. But as one of the first centres, it was difficult to promote it in a way that would not raise expectations in areas which did not have centres.

REFERENCES

1 Which? January 2001, pages 7-9.

2Department of Health. NHS Walk-in Centres. Full reference to come.

Key points

A walk-in centre opened in Liverpool in April 2000 is now seeing more than 3,000 patients a month.

Many patients use the service for emergencies.

More than half those attending do not need referral elsewhere.

Initial wariness on the part of local GPs to the project seems to have been largely overcome.

The centre opens at 7am but there is often a peak in demand at 9am.

Therese Patten is project manager, Old Swan walk-in centre, Liverpool. Mark Brandreth is community services manager, North Mersey Community trust