woking and weybridge nhs walk-in centres: local evaluation 2000-2002 dr susan turnbull on behalf of...
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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
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Acknowledgements (1)Ross Lawrenson
John Roberts
Surrey Social and Market Research, University of Surrey: Rosemarie Simmons and Elaine Bowyer
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WICLE Steering Group Graham Browning
Chris Dunstan
Lou Major
Sara McMullen
Iain McNeil
Vincent O’Neill
Stephen Price
Pauline Rogers
Cathy Winfield
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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
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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
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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
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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
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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”
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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
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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
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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
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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
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Location
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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
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Framework: Maxwell’s 6 dimensions of healthcare quality
Access
Equity
Effectiveness
Appropriateness
Acceptability
Efficiency
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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’)
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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
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Sex: WokingFemales 53.2%
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Sex: WeybridgeFemales: 55.8%
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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
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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
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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
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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
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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
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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
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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%)
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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
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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
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Weybridge WIC Ward-based visit frequency with increasing Townsend deprivation score
-5
-4
-3
-2
-1
0
1
2
St.G
eorg
e's
Hill
Wal
ton
Sou
th
Add
lest
one
St.P
aul's
She
pper
ton
Tow
n
Wal
ton
Cen
tral
Oat
land
s Pa
rk
New
Haw
Fox
hills
Wey
brid
ge S
outh
Byf
leet
Che
rtse
y M
eads
Her
sham
Sou
th
Add
lest
one
Bou
rnes
ide
Her
sham
Nor
th
Add
lest
one
Nor
th
Wal
ton
Am
bles
ide
Wey
brid
ge N
orth
Wal
ton
Nor
th
Che
rtse
y S
t.Ann
's
Ward
To
wn
se
nd
De
pri
vati
on
Sco
re
0%
5%
10%
15%
20%
25%
30%
Fre
qu
en
cy a
s %
war
d p
op
ula
tio
n
Tow nsend Score
Freq as % w ard pop
Weybridge WIC Ward-based visit frequency with increasing Townsend deprivation score
-5
-4
-3
-2
-1
0
1
2
St.G
eorg
e's H
ill
Walt
on S
outh
Add
lesto
ne S
t.Pau
l's
She
pper
ton
Tow
n
Walt
on C
entra
l
Oat
lands
Par
k
New
Haw
Fox
hills
Wey
bridg
e So
uth
Byf
leet
Che
rtsey
Mea
ds
Her
sham
Sou
th
Add
lesto
ne B
ourn
eside
Her
sham
Nor
th
Add
lesto
ne N
orth
Walt
on A
mbles
ide
Wey
bridg
e No
rth
Walt
on N
orth
Che
rtsey
St.A
nn's
Ward
Tow
nsen
d De
priv
atio
n Sc
ore
0%
5%
10%
15%
20%
25%
30%
Freq
uenc
y as
% w
ard
popu
latio
n
Tow nsend Score
Freq as % w ard pop
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Weybridge WIC Townsend deprivation score with increasing ward-based visit frequency
-5
-4
-3
-2
-1
0
1
2
She
pper
ton
Tow
n
Fox
hills
Che
rtsey
St.A
nn's
Che
rtsey
Mea
ds
Wal
ton
North
Wal
ton
Am
bles
ide
New
Haw
Wal
ton
Sout
h
Byf
leet
Her
sham
Nor
th
Add
lest
one
St.P
aul's
Wal
ton
Cent
ral
Add
lest
one
North
Her
sham
Sou
th
Add
lest
one
Bour
nesi
de
Oat
land
s Pa
rk
Wey
brid
ge S
outh
St.G
eorg
e's
Hill
Wey
brid
ge N
orth
Ward
Tow
nsen
d De
priv
atio
n Sc
ore
0%
5%
10%
15%
20%
25%
30%
Freq
uenc
y as
% w
ard
popu
latio
n
Tow nsend Score
Freq as % w ard pop
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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
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
nta
ge
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
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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
ge
Weybridge: Visits as % of practice list size - top 12 GP practices
0
5
10
15
20
25
Per
cen
tag
e
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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
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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
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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
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Proportion of visits by discharge recommendation
05
101520253035404550
Discharge (1)
% o
f vi
sits Wok fem
Wok male
Wey fem
Wey male
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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%
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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
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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
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‘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
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‘Alternative’ = GP by ‘discharge’
0
10
20
30
40
50
60
Discharge (1)
% o
f vi
sits
Woking
Weybridge
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‘Alternative’=A&E by ‘discharge’
05
101520253035404550
Discharge (1)
% o
f vi
sits
Woking
Weybridge
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‘Alternative’= self care by ‘discharge’
010
2030
4050
6070
80
Discharge (1)
% o
f vi
sits
Woking
Weybridge
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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)
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•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
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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
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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
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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
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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)
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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
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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
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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
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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’
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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
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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
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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
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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
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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
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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
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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………………………..