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Do not have a meaningful impact on the demand for general practice
National Health Service walk-in centres were introduced in England in 2000. They are primarily led by nurses, have long opening hours, and provide advice and treatment for minor illnesses and injuries. NHS walk-in centres are intended to improve access to primary care and to reduce pressure on other providers of health care, such as general practices.1 A paper in this week's BMJ by Maheswaran and colleagues looks at whether they have achieved this second aim.2
Maheswaran and colleagues conducted an ecological study to determine whether proximity to a walk-in centre was associated with general practices meeting the NHS access target to offer an appointment within 48 hours. Using a series of sophisticated models, they found no evidence that walk-in centres led to shorter waits in general practice.2 This is consistent with several earlier studies, which found no impact of walk-in centres on consultation rates at other healthcare providers.3 4 5
The underlying hypothesis is that if people go to walk-in centres then demand on general practices will drop and the wait for an appointment will be reduced. But each step in this apparently logical argument is questionable. Firstly, if walk-in centres improve the accessibility of care this may lead to extra consultations as previously unmet demand is catered for6; also, some people go to walk-in centres and general practice with the same problem,7 8 so demand on practices may not be reduced. Secondly, any change in demand on general practice may not necessarily lead to changes in waiting times. Practices all have ways of accommodating changes in demand, such as offering extra appointments at the end of surgery or allowing patients to wait in an “open” surgery. Thirdly, even if walk-in centres did reduce demand in general practice, this would have a negligible effect because of the volume of people attending each type of site.
The average walk-in centre conducts about 35000 consultations each year,9 equivalent to the productivity of about five general practitioners. An earlier evaluation found that an average of 58 general practitioners work within 3 km of each walk-in centre,10 which greatly dilutes any potential impact of a walk-in centre on individual practices.
The study assesses the proportion of practices that met the NHS 48 hour access target, using data from the primary care access survey. However, the validity of this measure is debatable. This survey involves primary care trusts making telephone calls to practices to inquire about the availability of appointments, and until 2006 practices were informed in advance when the inquiry would be made. Practices and primary care trusts have strong financial incentives to report that targets are met, which might explain the discrepancy between the positive findings of the survey9 and patients' reported difficulties in making an appointment.11 Although an independent validation study supported the reliability of the survey, this was also based on non-anonymised calls to practices.12 My own recent research (under review), based on anonymised calls by simulated patients seeking to make an appointment, suggests that the primary care access survey substantially overestimates achievement of the access target.
What are the implications of Maheswaran and colleagues' paper for primary health care? It shows that walk-in centres are unlikely to have a meaningful impact on the demand for general practice unless they expand massively in number. This would be hard to justify given their higher cost per consultation and more limited range of services than general practice,10 and uncertainty about whether greater provision would lead to inflation of demand and duplication of services rather than substitution.
Can walk-in centres be justified on the grounds of their other aim, to increase the accessibility of care? They offer a popular and convenient route to care for patients who value not having to make an appointment to see a nurse.8 An alternative strategy would be to encourage more general practices to offer similar services. The widespread provision of practices, and economies generated by combining rather than duplicating facilities, mean this is likely to be a much more cost effective way to increase the accessibility of care.
Several other countries have walk-in centres, including the United States, Canada, Australia, and South Africa, but we need to be cautious in applying the findings of this study to other settings. The term walk-in centre is used to describe many types of facility, which have different roles in different countries. But one interpretation of this study is internationally relevant. Health care is a complex system in which demand and supply are related and met through an intricate web of provider organisations. Changes in the provision of care within one element of the system, particularly introducing an entirely new type of facility such as a walk-in centre, may not have the intended effects. It is important that we fully understand the contribution of different healthcare providers and how and why they are used by different groups of patients.
Competing interests: None declared.
Provenance and peer review: Commissioned; not externally peer reviewed.