Correspondence to Dr Mubashir Arain; [email protected]
Strengths and limitations of this study
This is the first study to explore the perceived impact of general practitioner-led (GP-led) walk-in centres in the UK on other urgent care services. The study included a wide range of stakeholders who could identify some potential issues that emerged as a result of the establishment of these centres.
This study provides valuable information regarding stakeholders’ perspectives and organisational implications of establishing GP-led walk-in centres.
While this is a small sample size, the achievement of data saturation indicates that the sample was adequate to address the research question in this context. The impact of these centres on emergency departments over a period that could be expected with this new service was beyond the scope of this study.
The qualitative findings from our purposive sample are not intended to be representative, but highlight important insights into barriers and enablers to conduct future large-scale research on the impact of GP-led walk-in centres on other National Health Service.
Introduction
The rise in the emergency department (ED) attendances has been of particular concern in the UK over the past few years.1 There have been many efforts to strengthen the primary healthcare services and to decrease the unnecessary attendances at EDs. In the past decade, multiple urgent care services have been introduced such as National Health Service (NHS) Direct, urgent dental services, walk-in centres and general practitioner (GP) out-of-hours services to decrease the unnecessary patient load on EDs.
The nurse-led walk-in centres were established in the early 2000s. The aim was to improve patient access to healthcare services for minor illness and injuries by having long opening hours—7:00 to 23:00, 7 days a week.2 Some of these centres also employed GPs, but they were mainly led by nurse practitioners.3 However, there were concerns about treatment continuity and safety.4 Moreover, GPs identified the need for better communication between nurse-led walk-in service providers and registered GPs. In contrast to these concerns from GPs, it has been reported that patient satisfaction with the quality of service is greater in nurse-led walk-in centres as a result of easy access and much shorter waiting times compared to GP practices.5
The GP-led walk-in centres were introduced in the UK following a report by the Department of Health on the situation of urgent care services.6 GP-led walk-in centres aimed to improve patients’ access to GPs and to reduce unnecessary patients’ visit to EDs. It was also expected that GP-led walk-in centres would address some of the concerns aforementioned about nurse-led walk-in centres. However, it was not clear whether these centres were going to replace the nurse-led centres or established in parallel to the nurse-led centres. The new model was different from the nurse-led model as private healthcare providers operated some of these centres. Moreover, patients could also register with the GPs working at these centres. Around 150 such clinics were planned to open in England.7 Although patient satisfaction is reported to be high with the services at these centres,8 some of the centres have already been closed down after only a few years of operation due to a lack of evidence for reductions in ED attendances.9 One report stated that 25% of GP-led walk-in centres disappeared due to budget cuts in 2012.10 A report by the King's Fund highlighted an urgent need to evaluate the impact of GP-led walk-in centres.11 There were other calls for a greater understanding of the potential role of GP-led walk-in centres in the urgent care system.12 Therefore, we conducted a mixed-method evaluation study of a GP-led walk-in centre in the UK. This paper focuses on the qualitative findings. The aim of the qualitative part was to determine the perceptions of healthcare professionals regarding the effectiveness and impact of a GP-led walk-in centre on other local NHS services in a single primary care trust (PCT).
Methods
This qualitative exploratory study was designed under the domain of phenomenological approach.13 Semistructured interviews were conducted from August 2012 to December 2012. Healthcare providers and healthcare managers were purposively sampled to achieve diversity in professional groups and the range of service locations within a single locality including: an ED at a large city hospital; an ED at a children's hospital; a minor injuries unit; the GP-led walk-in centre; GPs from surrounding surgeries and GPs from an academic unit of primary medical care. Participants were recruited until no new themes emerged (ie, data saturation).
MA conducted hour-long (on average) individual interviews in the participants’ offices using a semistructured interview guide developed by the authors, based on a previous study4 and also from informal discussions with the local PCT and GP-led walk-in centre manager. A one-hour appointment for the interview was requested, so the duration of interviews was predetermined. The interview guide covered the following topics: introduction to the participants’ role in the NHS and any role in relation to the GP-led walk-in centre; perceptions about the services provided at the GP-led walk-in centre; perceived effectiveness and impact of the GP-led walk-in centre on other services; and awareness of the general public about the services provided at the GP-led walk-in centre. All interviews were digitally audiorecorded and then transcribed into word format. Field notes were also taken.
The coding was primarily carried out by MA, with input from SB to discuss emerging codes and data within each theme, prior to discussing data with other members of the research team to establish consensus. Data were coded by hand using thematic analysis to identify recurring themes. Thematic analysis has been increasingly used in health services research.14 Each interview was read line by line to identify ideas or concepts within the text. Similar ideas or concepts across the transcripts were brought together and given a descriptive code. Each code was then further examined to develop themes and subthemes within the data set.
Informed written consent was obtained from all participants.
Results
Eleven participants were interviewed. The participants were broadly from two categories: first, healthcare professionals (consultants, GPs, nurses) and second, managers (GP-led walk-in centre managers, PCT managers). All the participants from the managerial group were either directly or indirectly involved in managing or commissioning the GP-led walk-in centre services. Of the non-managerial group, two healthcare professionals were from a minor injuries unit, two GPs were from surgeries near the walk-in centre, one participant was a GP practice coordinator/manager working within a mile radius of the walk-in centre, and three were doctors from the ED of the local hospital. Table 1 details the characteristics of participants.
Table 1Participant characteristics
| Female | 4 (36.4) |
| Experience (years) | |
| 0–5 | 3 (27.3) |
| 5–10 | 3 (27.3) |
| >10 | 5 (45.5) |
| Organisation of work | |
| GP-led walk-in centre | 1 (9.1) |
| PCT | 2 (18.2) |
| ED minor injuries unit | 2 (18.2) |
| ED | 3 (27.3) |
| GP surgeries near the walk-in centre | 3 (27.3) |
| Role | n/total* |
| Operational manager (GP-led walk-in centre) | 1/1 |
| PCT manager | 2/2 |
| ED nurse practitioner | 2/5 |
| ED Registrar | 1/unknown |
| ED consultant | 2/6 |
| GP | 2/4 |
| GP practice manager | 1/1 |
*Total shows the denominator, which was the number of potential participants available in each professional group.
ED, emergency department; GP, general practitioner; PCT, primary care trust.
On exploration of the perceptions, seven recurring themes were identified that were directly or indirectly related to how local healthcare providers and managers perceived the role of the GP-led walk-in centre in the urgent care system. The themes include uncertainty regarding the clinical model of the GP-led walk-in centre; lack of public awareness about the services provided; uncertainty regarding the impact of the GP-led walk-in centre on other NHS services; increasing demand for healthcare services; concerns regarding appropriate use of the centre; the creation of choice and confusion; and mixed views of the services provided (figure 1 illustrates themes and subthemes within the data).
Some quotes have been subject to minor editing (edits shown in brackets) to clarify the meaning of extracts and to maintain the anonymity of the participants. Furthermore, the source has been referred to only by the group in order to preserve anonymity.
Uncertainty regarding the clinical model
The participants described differing understandings regarding the existing model of the local GP-led walk-in centre and their preferred model.
Nurse-led versus GP-led
Some participants perceived that the GP-led walk-in centre was typically nurse-led and only made referrals to a GP when needed. Others believed that a triage nurse decides if a patient is going to see a doctor or a nurse. One participant reported that the payment received by the GP-led walk-in centre was to run a nurse-led service; however, if nurses were unavailable, the service would provide GPs without adding any extra cost to the PCT.
Service provided
They [the GP-led walk-in centre] usually provide GP services. So all the general GP services really…but walk-in…in a sense that really they are there for people who don't have access to GP whether because of problems with their appointments of by virtue of whether they are within or they are not within reach of GP. (Health Care Professional)
GP practice sent patient here for some blood results on a Saturday; we have people sending for ear syringing, that kind of things, which are not appropriate for a walk-in setting. (Manager)
The model of private providers
I think NHS services taken on by private industry are destined to become then money oriented. (Health Care Professional)
Lack of public awareness about the services provided
The GP-led walk-in centre had advertised its services in several places such as newspapers, magazines, flyers and local radio; however, most of the participants reported that the publicity was not enough to create awareness in the general public.
I think nobody reads the back of buses or reads pamphlets. (Health Care Professional)
I think GP surgeries certainly have a role in educating people about what services are appropriate. (Health Care Professional)
Uncertainty regarding the impact on other NHS services
It is still a problem even if [the GP-led walk-in centre] has reduced it [unnecessary patient load at ED], which I don't know. It has certainly not oversubscribed ED attendance because the problem is still there. (Health Care Professional)
[GP-led walk-in centre has] probably a combination of impact…on other GP practices and their out-of-hours GP services and the A and Es [accident and emergency departments]. (Manager)
The ED buildings are not big enough to cope with the numbers. Remember the GP walk-in centre has around 200 patients per day; that's an awful a lot of extra people for A and E [ED] waiting rooms. (Manager)
I think if you take it [GP-led walk-in centre] out then there will have no choice but to go and see the GP. (Health Care Professional)
Increased demand for healthcare services
A and E [ED] has not seen any reduction in their patients. If there is a service, patient[s] will use it. You could have three walk-in centres in the city and all three would be used and you may still not see any dropping in A and E [ED] counts. (Manager)
It creates an artificial need and probably does more harm in the long term. (Health Care Professional)
I think it probably duplicates what a general practice, urgent surgery or emergency surgery would see and what the GP out-of-hours would see. (Health Care Professional)
Concerns regarding appropriate use of the centre
Patients turning up to the GP walk-in centre wanting ear syringing, which is not something the walk-in bit does. (Manager)
Choice and confusion
Patient confusion
I think it's often confusing and difficult for people to decide what service they need; they need some assistance with that. (Health Care Professional)
The need for a ‘one front door’ service
I personally would like to see one front door in A and E [ED] and patients filtered into primary care stream, minor injury stream, or the main A and E department. (Health Care Professional)
If they [patients] go to one single place, they can be dealt with because of the availability of nurses, doctors, X-rays, blood tests all that kind of thing. I would advocate a single place, one door and one single point of access. (Health Care Professional)
Mixed (positive and negative) views of the GP-led walk-in centre
Participants had positive as well as negative views about the GP-led walk-in centre service as well as some views about the cost-effectiveness of the service.
Positive views
I think it is easier for patients who are living here [near city centre] to go to GP walk-in centre than to go to GP collaborative or ED, which is at [one] hospital, and is less preferable for patients. (Health Care Professional)
Obviously there would be patients who historically would go to an A and E [ED] are now going to the GP walk-in centre. I couldn't get an appointment for my daughter and I know she doesn't need to go to children A and E for conjunctivitis so I chose to go to the GP walk-in centre. (Manager)
Negative views
The service [GP-ledwalk-in centre] should not be continuing in the future. I think for several reasons, mainly in the interest of simplifying access to unscheduled care. (Health Care Professional)
It [the GP-led walk-in centre] had a negative effect on us. The PCT have established a health care provider within a one hundred and fifty-meter radius of the one that is there for thirty years. Patients can also register there. It definitely has an effect on our registration. Our registration has gone down. (Health Care Professional)
Cost-effectiveness concerns
I think that it's [GP-led walk-in centre] a very expensive service and as far as I understand it, they are paid on a sort of a patient contact or arrived-on-service basis, which means every time a patient walks in they receive a payment for that which is very different to GPs paid in primary care. I don't think it provides good value for money. (Health Care Professional)
Discussion
The views of the healthcare professionals and managers provide insight into the perceived effectiveness and model of care provided by a GP-led walk-in centre in one PCT. There were some discrepancies between the managers and healthcare professionals regarding the usefulness of the GP-led walk-in centre in the current urgent care system. Managers perceived that it was an important service that needed to be continued in the future to prevent any additional burden of patients on EDs. Most of the healthcare professionals, however, were not in support of the idea of alternative urgent services. Previous studies have shown that alternative services in the UK have failed to produce any impact on reducing unnecessary patient load at EDs.15 16 It has also been reported that alternative healthcare services confuse patients who may not be able to decide which service to choose in case of minor injury/illness.17 It is therefore important to address the concerns of all stakeholders before expecting the success of a walk-in service.18
The healthcare professionals were clearly in favour of ‘one front door’ service, which would move all unscheduled care services to an ED. This model has been used elsewhere in the UK where patients with minor problems are redirected from an ED to a co-located nurse-led walk-in centre.19 However, one study has shown that co-location of nurse-led walk-in centres with EDs does not reduce patient load at EDs.20
Studies have shown that alternative services may not reduce patient load at EDs.21 22 In contrast, one study conducted on the new model of GP-led walk-in centres has shown a significant reduction in minor illness/injury attendances at an ED after the opening of the centre.23
Improvement in patient access to healthcare services has been shown to decrease unnecessary hospital admissions for patients with chronic disease.24 Thus, it could be anticipated that the improved access to primary care services would reduce unnecessary patient visits to EDs. GP-led walk-in centres are mostly located in the centre of the city/town, so the geographical access to healthcare services might have improved. Also, functional accessibility has been improved as a result of longer opening hours. Moreover, the opening of the centres on weekends and bank holidays improved accessibility for those who otherwise were less likely to access their GPs.
Unawareness of alternative services is a major reason for not having reduction in the patient load at EDs. One study reported that only a few patients at an ED were aware of an alternative urgent care centre which was co-located with the ED.25 Another paper has shown that around half of the patients at an ED were unaware of the existence of the GP out-of-hours or walk-in centre services.21 Publicity materials should be available to a wider population through GP surgeries, hospitals and other healthcare services. Publicity material can be improved by clearly indicating the purpose of establishing the GP-led walk-in centre and focusing on the differences between different urgent care services.
Healthcare professionals were unaware of the activity data at the GP-led walk-in centre. There are two possible reasons for this: first, the suboptimal communication between the GP-led walk-in centre and other healthcare providers regarding the available services at the centre, and second, the GP-led walk-in centre does not have an active role in the urgent care services provision. Participants were also concerned about the service being provided by the private sector. The service was free of cost for users and the GP-led walk-in centre charged the NHS for every patient visit. There is a major difference in commissioning a standard GP surgery and GP-led walk-in centre; standard GPs are paid yearly on the number of registered patients while GP-led walk-in centre is paid for per patient visit. The other important concern was that the GP-led walk-in centre was placed in the centre of the city where other GP surgeries were also operating in the surrounding. A few participants reported that the centre was potentially attracting patients who otherwise would attend a GP in the surrounding, creating a competitive environment between a GP-led walk-in centre and other GP surgeries. The services provided by a private healthcare provider created further concern about the competition between standard GP surgeries and the newly established GP-led walk-in centre. Many patients might have registered at the GP-led walk-in centre because of the longer opening hours and easy access. The other GP surgeries were unable to offer 12 h a day service to compete with the facility that the GP walk-in centre was offering. Thus, measures need to be taken to prevent any decline in the number of registered patients in the surrounding GP surgeries wherever such a centre has been established.
There were some limitations of this study. First, interviews were only conducted in one city, and therefore our findings may not be applicable to other health service locations. Second, only GPs from a surgery near the GP-led walk-in centre were included in the study and other healthcare professionals, such as dental practices and urgent dental care services, were not included. Third, there was small representation from each professional group because of the small study sample. However, our conclusions do not go beyond what the data could support. The findings do not quantitatively determine how many physicians or nurses believed what this paper says, but it does add general perceptions about the centre. Lastly, there was another limitation that most of the analysis and all interviews were done by one person.
Conclusion
Participants did not notice declines in the demand for EDs after the GP-led walk-in centre opened in the locality. Most of the healthcare professionals believed that the GP-led walk-in centre duplicated existing healthcare services. It was also a common belief of healthcare professionals that the general public was unaware of the existing alternative healthcare services and patients often struggle to decide which healthcare service to go to when a GP appointment is unavailable.
There is a need to have a better communication system between the GP-led walk-in centres and other healthcare providers to have an integrated system of urgent care delivery.
GP-led walk-in centres could potentially attract patients from surrounding GP surgeries. We recommend that future large-scale studies need to examine the impact of GP-led walk-in centres on surrounding GP surgeries as well as on EDs.
The authors would like to acknowledge the support of the institutes that participated in this research and enabled us to carry out data collection at these sites. They also acknowledge Jill Norris, Faculty of Nursing, University of Calgary, for her support in editing the manuscript.
Contributors JPN and MA planned the overall evaluation project. JPN participated in the design. MA carried out the data collection for the study. SB and MA coded the data and performed thematic analysis with some input from JPN. All the authors read and approved the final manuscript.
Competing interests None declared.
Patient consent Obtained.
Ethics approval Ethical approval for the study was obtained from the Yorkshire and Humber NHS Ethics Committee (reference number: 10/H1304/31).
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement No additional data are available.
1 Gillam S. Rising hospital admissions. BMJ 2010; 340: 275–6. doi:10.1136/bmj.c275
2 Desborough J, Forrest L, Parker R. Nurse-led primary health care walk-in centres: an integrative literature review. J Adv Nurs 2012; 68: 248–63. doi:10.1111/j.1365-2648.2011.05798.x
3 Mabrook AF, Dale B. Can nurse practitioners offer a quality service? An evaluation of a year's work of a nurse led minor injury unit. J Accid Emerg Med 1998; 15: 266–8. doi:10.1136/emj.15.4.266
4 Pope C, Chalder M, Moore L, et al. What do other local providers think of NHS walk-in centres? Results of a postal survey. Public Health 2005; 119: 39–44. doi:10.1016/j.puhe.2003.12.014
5 Salisbury C, Manku-Cott T, Moore L, et al. Questionnaire survey of users of NHS walk-in centres: observational study. Br J Gen Prac 2002; 52: 554–60.
6 Darzi A. High quality care for all: NHS next stage review final report. London: Department of Health, 2008. http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/en/publicationsandstatistics/publications/publicationspolicyandguidance/DH_085825
7 Imison C, Naylor C, Maybin J. Under one roof: will polyclinics deliver integrated care? London: King's Fund, 2008.
8 Arain M, Nicholl J, Campbell M. Patients’ experience and satisfaction with GP led walk-in centres in the UK; a cross sectional study. BMC Health Serv Res 2013; 13: 142–51. doi:10.1186/1472-6963-13-142
9 NHS walk-in centre to close and hours to be cut at another. Yorkshire Post. 27 September 2011. http://www.yorkshirepost.co.uk/news/nhs-walk-in-centre-to-close-and-hours-to-be-cut-at-another-1-3811300
10 Wheeler B. Are NHS walk-in centres on the way out? BBC News. 28 June, 2012. http://www.bbc.co.uk/news/uk-politics-18503034
11 Gregory S. General practice in England: an overview. London: King's Fund, 2009. http://www.kingsfund.org.uk/sites/files/kf/General-practice-in-England-an-overview-Sarah-Gregory-The-Kings-Fund-September-2009.pdf
12 Lane J. NHS walk-in centres are dying out. Pharmafield Blog. 3 June, 2013. http://www.pharmafield.co.uk/be/post/2013/06/03/NHS-walk-in-centres-are-dying-out.aspx
13 Penner JL, McClement SE. Using phenomenology to examine the experiences of family caregivers of patients with advanced head and neck cancer: Reflections of a novice researcher. Int J Qual Methods 2008; 7: 92–101.
14 Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006; 3: 77–101. doi:10.1191/1478088706qp063oa
15 Chalder M, Sharp D, Moore L, et al. Impact of NHS walk-in centres on the workload of other local health care providers: time series analysis. BMJ 2003; 326: 532–7. doi:10.1136/bmj.326.7388.532
16 Munro J, Sampson F, Nicholl J. The impact of NHS Direct on the demand for out-of-hours primary and emergency care. Br J Gen Pract 2005; 55: 790–2.
17 Lattimer V, Burgess A, Knapp F, et al. The impact of changing workforce patterns in emergency and urgent out of hours care on patient experience staff practice and health system performance. Final report for the National Institute for Health Research Service Delivery and Organisation Programme. London: HSMO, 2010.
18 Parker RM, Desborough JL, Forrest LE. Stakeholder perceptions of a nurse led walk-in centre. BMC Health Serv Res 2012; 12: 382. doi:10.1186/1472-6963-12-382
19 Lattimer V, Brailsford S, Turnbull J, et al. Reviewing emergency care systems I: insight from system dynamics modelling. Emerg Med J 2004; 21: 685–91. doi:10.1136/emj.2002.003673
20 Salisbury C, Hollinghurst S, Montgomery A, et al. The impact of co-located NHS walk-in centres on emergency departments. Emerg Med J 2007; 24: 265–569. doi:10.1136/emj.2006.042507
21 Penson R, Coleman P, Mason S, et al. Why do patients with minor or moderate conditions that could be managed in other settings attend the emergency department? Emerg Med J 2012; 29: 487–91. doi:10.1136/emj.2010.107276
22 Coleman P, Irons R, Nicholl J. Will alternative immediate care services reduce demands for non-urgent treatment at accident and emergency? Emerg Med J 2001; 18: 482–7. doi:10.1136/emj.18.6.482
23 Arain M, Campbell M, Nicholl J. Impact of a GP led walk-in Centre on NHS Emergency departments. Emerg Med J 2015; 32: 295–300. doi:10.1136/emermed-2013-202410
24 Bindman AB, Grumbach K, Osmond D, et al. Preventable hospitalizations and access to health care. JAMA 1995; 274: 305–11. doi:10.1001/jama.1995.03530040033037
25 Land L, Meredith N. An evaluation of the reasons why patients attend a hospital Emergency Department. Int Emerg Nurs 2013; 21: 35–41. doi:10.1016/j.ienj.2011.12.001
Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions 2015 This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ Notwithstanding the ProQuest Terms and Conditions, you may use this content in accordance with the terms of the License.