Reading the Consultation document:
- the centre is not being appropriately used
- the type of care that needs to be provided can be provided outside of the Walk-In Centre
- the Walk-In Centre is a waste of budgetary resources
- the Walk-In Centre has contributed to health inequity in Lincolnshire.
With regards to "wasting budgetary resources", I fail to see how a service that has been regularly described as "fantastic" and has a 95% approval rating on the NHS website could be seen as "wasteful"; if patients are being provided with the advice, guidance and treatment needed to help them recover, especially if they have sustained a minor injury, then I believe the service cannot be categorised as wasteful. Lincs West CCG say they need to reduce "overlapping of services" in order to increase efficiency but does the plan that they have proposed do that without reducing the accessibility (and perhaps quality) of patient care?
The key component of the plan put forward by Lincs West CCG to accommodate the needs of those patients whose access to medical advice and treatment may become restricted due to the closure of the Walk-In Centre (because of their shift patterns or they feel they need to see a health professional for advice and reassurance) is to rely on GP surgeries around Lincoln extending their opening hours and ensuring the Lincs West CCG area has some form of accessible service for medical advice, guidance and minor treatment available 7 days a week, through a hub of several GP practices who will offer such a service. There would also be an increase in Skype consultations available for students who'd be happy to receive medical advice and guidance online and convenient access to GP services in surgeries near the University of Lincoln and Lincoln College. That's positive news for students but what about other service users?
Increasing "capacity" in GP surgeries so that patients can access appointments, including ensuring that children under 12 have access to an appointment on a same-day basis is a great idea in theory but of course I am naturally sceptical. My family's experience of obtaining appointments with our local GP surgery, Birchwood Medical Practice has generally been positive; in the past I've been able to ring the reception up when I've had ear complaints and I've been seen on a same-day or next-day basis (I've never been left more than a week to have an appointment with a GP). When I wanted to see my GP to take the baseline tests needed to start the application process for the Gender Identity Clinic in Nottingham, I was able to get an appointment slot that was available the week after I phoned reception. My Dad has been slightly less lucky but still he has been seen by his GP within the 2 week waiting period, even for flu advice. However, I've read of patients who have regularly waited over 2 weeks to see a GP to discuss issues related to stress and/or anxiety and some patients have even been advised by their GP surgery to attend the Walk-In Centre so they can be seen quicker. Same-day appointments are avaliable at my local GP surgery but you have to phone up at around 8am and ensure you have time during the day to go to the surgery and those appointments often are during office working hours. That's not always possible if you have an employer who is not flexible and won't give you time off to attend the appointment; very few people want to take a day off unpaid at short-notice to attend if they can help it. Attending the Walk-In Centre before the start of the working day is convenient for parents who want to get some urgent reassurance about their child's earache or women who need emergency contraceptive advice. The suggestion in the report to have walk-in centres in GP surgeries and extended opening hours would go some way towards providing an element of convenience provided that GP surgeries across the Lincs West CCG area are prepared to provide those services. If they do not, then there really will be an inequity in service provision.
Another aspect of the Lincs West CCG plan outlined in the consultation document is to try and get more patients to self-care through accessing information online and asking pharmacists for basic advice and guidance. Pharmacists are trained to give advice on a number of medical conditions including hay fever, athlete's foot and indigestion (see more here: http://www.nhs.uk/Livewell/Pharmacy/Pages/Commonconditions.aspx). Now a stat has been
bandied about by Lincs West CCG in the consultation document which states that "95% of patients who attend the Lincoln Walk-In-Centre do not require treatment". 50% of those 95% of patients "received advice and guidance only" and the consultation document suggests that those patients "would benefit from access to self-care support initiatives". I'm all for public health initiatives wherever appropriate but the consultation document does not specifically suggest whether such initiatives are being planned currently for the Lincs West CCG area, which areas those initiatives would focus on addressing and how much it would cost to create and then roll-out those initiatives. The survey document does talk about the various ways that Lincs West CCG may disseminate information; I believe that all of the methods suggested are appropriate, especially use of social media, newspaper articles and bus adverts.
I personally think it would be an excellent idea for LCHS and Lincs West CCG to look at creating an initiative that raises awareness of the role in pharmacies in helping to offer basic medical advice and guidance to help patients with their self-care treatment but I've never seen any initiatives at a national level either in newspapers, on the TV or on social media that have encouraged patients to ask them for advice and guidance. Also, it's relevant to mention that there have been plans to cut to pharmacist funding (through the Drug Tariff) of 6% - that's been worked out as approximately £14,500 per pharmacy. This could mean community pharmacists having to make cuts to overheads and that may include reducing staff. If there are less staff in pharmacies across our area, it means there are less staff who have the time available to properly advise patients; sometimes a 2 minute slot isn't enough to allay the concerns of a patient and given that the NHS should be a patient-driven service, it may be unrealistic to expect pharmacists to entirely take over the advisory role from community health nurses and GPs. I'd feel uncomfortable as a dyspraxic patient with only being given basic information if I had a recurrence of my recent kidney stone within a 2 minute time slot; it took a 15 minute slot with a GP at the Out-Of-Hours Service at Lincoln County Hospital A&E earlier this year to allay my fears and allow me to ask the questions and take-in the information I needed to help fight the pain and pass the stone naturally. Patients with complex learning differences and/or complex health needs may require longer. Capacity must remain in place within our local NHS trusts, including LCHS to facilitate appropriate time-slots with nurses and GPs to provide an advice and guidance service to patients with complex health needs.
The consultation document also highlights the importance of the NHS 111 service to providing advice and guidance to patients and argues that increasing the capacity within the 111 service (i.e. more call handlers) will help to bridge any potential gap that would be left with the closure of the Walk-In Centre. I've read numerous comments about the 111 service online from Lincoln residents and I have to say that not many of them are particularly complimentary. It appears that there is a problem with consistency; the quality of advice and guidance given by call handlers on the general 111 service can be quite patchy. I've been fortunate to benefit from the 111 service when I was suffering from severe kidney pain that I later found out in hospital was the result of a kidney stone (I've had them twice since 2013). The nurse that I spoke to was extremely polite, encouraged me to keep calm and eventually suggested I attend Lincoln County A&E directly to get access to specialist pain relief (I needed morphine because the level of pain was so bad ibuprofen and paracetamol combined couldn't touch it). However, I realise that the nurse on the phone may have been able to help me specifically because I was able to describe my symptoms in some detail (despite being in agony) and I had told him about my visit to the GP surgery a few days before, complaining with pain on my right hand side. Yet a patient who's not able or is uncomfortable with describing symptoms to a stranger over the phone will not have been able to access the specific advice and guidance that I received. The 111 service call handlers haven't always been able to gage the seriousness of a medical condition over the phone and that means that patients are having to resort to going to the A&E or the Walk-In Centre in order to ease symptoms and get the reassurance they need.Equally homeless patients and patients who are being subjected to sustained domestic violence and abuse by a controlling partner may be unable to have access to a mobile phone to ring the NHS 111 service and thus rely on being able to walk-in anonymously to receive medical advice and treatment.
What's important to note is that in Lincs, the NHS 111 service call handlers can now pass patients onto a Clinical Assessment Service (CAS) staffed by healthcare professionals who have specialist knowledge of Lincs and have access to patient records. The CAS was established in 2016 to provide patients with appropriate advice and guidance and signpost them to other NHS services wherever appropriate. Or that's how the service is meant to work in theory. My friend who had severe pain in his neck for more than a week was told by a CAS professional that he should just take some paracetamol and rest until the pain went away; the paracetamol did not touch the pain and he eventually collapsed in the evening and was taken to A&E in an ambulance. Deeply worrying given that the NHS website suggests that someone with a stiff neck for more than a week should see their GP or be given advice to see their GP. An example of patchy guidance that needs to be ironed out in the future.
Further Questions: The Lincolnite Interview:
Representatives from the Lincs West CCG Governing Body, Dr Sunil Hindocha, Chief Clinical Officer and Chief Operating Officer Sarah-Jane Mills had a recent interview with The Lincolnite (http://thelincolnite.co.uk/2017/06/closing-lincolns-walk-in-centre-is-the-right-thing-to-do-say-ccg-bosses/) which discussed the reasons why they felt that they needed to close the Walk-In Centre. A number of claims were made during the interview which made me think further about the proposal:
- Dr Hindocha claims that 2/3 of patients who attend the Walk-In Centre do not receive any treatment at all; that directly contradicts the stats given in the consultation document. Confusing?
- Dr Hindocha says that a number of patients who used the walk-in-centre then had an appointment with him on the same day; was that because they'd manage to get a very rare same-day appointment after being advised by a walk-in-centre professional to see their GP or were advised by the Walk-In Centre to contact their GP to gain access to repeat prescriptions or doctor's notes, which cannot be provided by the Centre?
- According to Sarah-Jane Mills, over 20% of the patients attending the Walk-In Centre are University students (not sure whether they are from the University of Lincoln only or also from Bishop Grosseteste University...he doesn't provide that level of detail); does that mean GP surgeries located near the University of Lincoln need to have extended opening hours or offer more walk-in services or does there need to be another GP surgery established in the area?
- Dr Hindocha argues that numbers of Lincoln Walk-In Centre attendees are falling because of online services....where's the objective empirical evidence to back that claim up? It's not in the consultation document!
- A number of GP surgeries have a walk-in service but:
- where are these GP surgeries located (are there some outside of the City of Lincoln boundaries)?
- which of those GP surgeries have a walk-in service that doesn't require prior booking (i.e. do not need to telephone the receptionist in advance)?
- is the walk-in-service only available at certain times of the day (usually in the morning)?
- why aren't GP walk-in services being properly advertised so that patients in the local area are AWARE that those services exist?
- Reference is made by Sarah-Jane Morris to "different types of GP surgery appointments" being made available to patients; how many extra on average will be made available to patients needing to see a GP, how many extra on average will be made available to patients who only need to seen a Nurse Practitioner?
- Dr Hindocha says there is "no evidence" in the dataset he has seen to show that more patients would attend A&E if the Walk-In Centre is closed because they'd go to pharmacists to receive "limited self-care information" - where's the empirical evidence from objective studies carried out in other areas of the UK where Walk-In Centres have been closed to back this claim up?
- Dr Hindocha states the obvious that the Walk-In Centre was not designed with A&E patients primarily in mind but there may be patients who will attend A&E if they cannot get a GP appointment when the Walk-In Centre is no longer in Lincoln.
- There will be same-day appointments available (including for non registered patients) but only if patients "clinically require it" (only guaranteed to children under 12). Where will patients be signposted to if they are deemed "fit enough" to receive advice and guidance elsewhere? Pharmacists or online services? Will there be differentiation in signposting according to individual patient needs?
- Currently a shortage of GPs in Lincolnshire but Sarah-Jane Morris states that Lincs West CCG are the "leading recruiter of international GPs" in England and have managed to get 27 to join; this is excellent news but will this number be sufficient to fulfill demand for extended GP surgery opening hours and a GP surgery walk-in service?
- Dr Hindocha claims that in the 4-5 busiest GP practices in Lincoln, 2-3 additional appointments will be necessary to fulfill demand; is this on a daily basis?
- What specific improvements need to be made to the NHS 111 service so that more patients that require specific advice and guidance get the specific support they need?
- Conversations about service provision have been ongoing and all NHS trusts based in the Lincs West CCG area have had a chance to have their say on the proposal to close the Walk-In Centre including the risks involved with primary patient care; I wonder what they have said about facilitating the health care provision required for homeless patients and tourists?
- One of the risks identified concerns the flow of information to patients about alternative NHS services; how are Lincs West CCG going to help local NHS trusts to disseminate that information if the Walk-In Centre is closed (we'll hopefully find out after the Consultation process has been concluded!)
- What would happen if there was a major incident in Lincoln and there was no Walk-In-Centre to take the overspill of patients who have minor ailments who were not involved in the incident?
- There is also the question of where the money (£1m a year) saved from axing the Walk-In Centre will be directed to within the Lincs West CCG budget:
- Would it be used towards the recruitment of GPs to alleviate pressure on surgeries and fill remaining vacancies?
- Would it be used to recruit more GP surgery nurses or community health nurses?
- Would it be used to improve the quality of the 111 service?
- Would it be used to put in place specialist health services for the homeless in Lincoln?
- Or has the money already been reallocated to the GP streaming service planned for outside the A&E department in the car park area at Lincoln County Hospital as has been alleged by a NHS Whistleblower (read The Lincolnite article here and judge for yourself: http://thelincolnite.co.uk/2017/06/lincoln-walk-centre-closure-consultation-lie-says-whistleblower/).
- Dr Hindocha states that closing the Walk-In Centre is not about saving money but streamlining services to "move to a new model of care" with an emphasis on utilising new technology to deliver service and relying on self-care initiatives. Not every patient is going to want to have a Skype consultation though, as I've highlighted earlier.
- Sarah-Jane Morris seemed to suggest that even a large number of responses against the closure of the Walk-In Centre may not change the mind of Lincs West CCG because they believe they are acting in the best interests of patients. Hmm! Hopefully the consultation process does help Lincs West CCG understand the needs of the local population but also those who may be visiting the area too!
I still feel that closing a NHS service that has received a number of excellent reviews on the NHS Choices website (95% of patients have recommended the service) and is described as ""an asset to Lincoln" that ""provides vital and essential care for the local community" is a great shame. I don't believe the Walk-In Centre should close until at least ALL GP surgeries have extended opening hours and a walk-in service in the majority of those GP surgeries is guaranteed. I also want to have some indication as to where the money that has been saved from closing the Walk-In Centre will be redirected to. I've also heard no specific plans that would be put in place to ensure tourists gain access to minor treatment and prescriptions without having to attend A&E and to offer healthcare directly to homeless patients on the streets of Central Lincoln. With all this in mind, I cannot personally support the Lincs West CCG plans in their current form. I have already signed the petition to keep the Walk-In Centre open (like 4,547 others; patients based in the Lincs West CCG area can sign it here: https://www.change.org/p/save-lincoln-s-only-gp-walk-in-centre-from-closure?utm_source=embedded_petition_view) and I support the right of Lincolnshire residents and patients to continue to protest against Lincs West CCG for their plan; there's already been a protest that was organised by UNISON outside Lincoln County Hospital on Wednesday 5th July and another was held on the 12th July at 10am outside the Lincs County Council offices. Labour's group on Lincs County Council have also made it crystal clear that they do not support the plans and brought a motion to try and oppose the proposed closure of the Walk-In Centre but I hope that the health scrutiny committee at Lincs County Council will properly look at the plans when they meet on July 19th.
I urge anyone interested in the future of healthcare provision in Lincoln to respond to the consultation and fill in the survey; you can do so here: https://www.surveymonkey.co.uk/r/wic-consultation. You now have until August 18th to respond.