Thursday, 13 July 2017

Lincoln Walk-In Centre Consultation: My Thoughts

I'm concerned by the proposal put forward by Lincolnshire West Clinical Commissioning Group (CCG) to close Lincoln's only Walk-In Centre located on Monks Road. Not only is the centre used by central Lincoln residents and Lincoln College, Bishop Grosseteste University and University of Lincoln students, there are a number of patients who have travelled to the Walk-In Centre from villages such as Skellingthorpe, Waddington and towns such as Gainsborough because they are seeking immediate medical advice and treatment which they are currently unable to access through their local GP surgery. Lincoln's Walk-In Centre, which is part of the Lincolnshire Community Health Services NHS Trust (LCHS) opened in April 2009 and has a dedicated team of 15 which is nurse-led. The Centre is open from 8am to 8pm 7 days a week (except on Christmas Day and Easter Sunday) and aims to see patients within 30 minutes of being booked in at the reception. The team provides a range of minor treatments, including treating minor scalds and burns, insect bites and stings, minor skin infections and offering health screening advice. They can't deal with drug overdoses or severe allergic reactions so those patients are encouraged to make a GP appointment or attend A&E if they need emergency treatment. The Walk-In Centre staff can't issue doctors certificates or repeat prescriptions and patients are usually advised to contact their GP surgery to arrange these but there's no doubt that the Walk-In Centre is providing vital frontline treatment to patients; the team treated a total of 34,470 patients during the last financial year, with the centre costing just over £1m to operate. Lincs West CCG currently have a budget of £380m, so the centre's operating costs are an extremely small proportion of the budget.  The Walk-In Centre was built in order to help reduce Lincoln County Hospital A&E admissions and to allow patients to access medical advice and treatment regardless of whether they are registered with a local GP surgery or not. Lincs West CCG now argue that because of service improvements (the introduction of NHS 111 service for example), patients no longer need to access the Walk-In Centre to receive primary care. They say they need to close the Walk-In Centre to reduce "duplication of services" and improve efficiency. It seems to me that there is such a drive towards efficiency in the NHS and all of our public services these days but it must not come at the expense of patient care and safety.

Reading the Consultation document: 


To help inform the decision making process of patients, healthcare professionals and representatives from local organisations who have decided to respond to the proposal put forward by Lincs West CCG (through filling in surveys, attending drop-in centre meetings and conversing and emailing our newly elected Labour MP, Karen Lee (500 people talked to her about the proposals in Lincoln on Sat 1st July 2017 alone), a consultation document has been provided to give basic information: (http://www.lincolnshirewestccg.nhs.uk/wp-content/uploads/2017/06/Lincoln-Walk-in-Centre-Consultation-Document.pdf). 

The document gives 4 reasons as to why the Walk-In Centre needs to close, which are: 
  1. the centre is not being appropriately used
  2. the type of care that needs to be provided can be provided outside of the Walk-In Centre
  3. the Walk-In Centre is a waste of budgetary resources
  4. the Walk-In Centre has contributed to health inequity in Lincolnshire.
Let me address the fourth reason because I believe it's the most ludicrous. Lincs West CCG claims that maintaining the Walk-In Centre has led to "an inequity in service" provision in the area because the majority of patients who use the centre are registered with a GP and are resident in Central Lincoln wards but they provide no empirical data in the consultation document to back this claim up. It also begs the question whether GP provision in Lincoln wards such as Abbey are appropriate to meet the needs of residents. It's rather rude to suggest that patients who are registered with GPs are somehow enjoying a more privileged service when all they want is to be able to see a health professional to discuss their health condition and get some reassurance face-to-face. Blaming patients for using the Walk-In Centre service that was established because there was (and still seems to be) a need in Lincoln is not good enough and besides, as I've already mentioned above, the operating costs of the Walk-In Centre are miniscule compared to the overall budget and the Lincs West CCG have not provided evidence to show how they are going to improve equity of service across the Lincs West CCG area. 

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.

Another problem with Lincs West CCG's plan that immediately springs to mind is that it doesn't reflect the fact that the types of patients who visit the Walk-In Centre aren't necessarily ones who are registered with Lincoln based GPs in the first place (despite the fact that Lincs West CCG claim that the majority of patients are registered with GPs (no percentage given) and from central Lincoln). We need to know what would happen to those patients when the Walk-In Centre closes. How can we deliver quality healthcare to homeless patients, who may need urgent access to treatment, especially if they develop symptoms of flu or fever overnight when the temperatures dip below 0C during the winter months? How do we deliver healthcare to those patients who travel in from surrounding villages and towns who are unable to get into a GP surgery because they have no spaces available? What about tourists coming into Lincoln for events such as Lincoln Pride and the Christmas Market? Will they be able to access a GP appointment at short notice or will they be forced to attend an an already incredibly busy A&E department at Lincoln County Hospital where a 5 hour wait is currently the norm? I'd like to see specific figures published by Lincs West CCG detailing the number of non GP registered patients who attended the Lincoln Walk-In Centre who were homeless or tourists and I'd like to see evidence in their plans that definitively prove that the closure of the Walk-In Centre will not detrimentally impact on the health care of our homeless population and tourists (from the EU and outside the EU).

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! 
From hearing the interview and reading the consultation document, it seems apparent that there is an expectation from Lincs West CCG that walk-in services  may become the norm at most, if not all GP surgeries across the Lincs West CCG area. Of course GP surgeries will be mandated to offer a 7 day routine service for patients but it appears that it may not be established straight away (it has to happen within 3 years though) and that the service may be delivered through hubs as opposed to at every GP surgery. I think patients would on the whole welcome a move towards a more convenient and accessible local service, especially if they are based in towns such as Gainsborough or registered at 1 of the 4 or 5 busy GPs referred to be Dr Hindocha but I don't believe the Walk-In Centre should be closed until the provision is in place and the quality of service provision has been tested to see whether patient satisfaction levels match that recorded on the NHS website for the Walk-In Centre.  

Overall Thoughts: 


I believe that Lincs West CCG, working in conjunction with other Lincs based NHS trusts including LCHS must ensure that NHS services are available and accessible to all patients that happen to be in Lincoln at the time they have a medical complaint. There's nothing wrong in theory about extending GP surgery hours (I think they should be extended to 7 days a week for ALL GP surgeries in the Lincs West CCG area and not just be delegated to hubs) but there must be also be some form of walk-in service available in GP surgeries that allows non-registered patients access to medical advice and guidance and minor treatment without them having to resort to using the A&E department at Lincs County Hospital; that includes treating homeless patients and tourists. I agree that the Out-Of Hours GP service (currently based at Lincs County Hospital) should be maintained as it helps to ease A&E pressures overnight. There needs to be more public awareness campaigns at a local and national level that encourage patients to have the confidence to call the NHS 111 service because of the CAS tie-in we now have in Lincs and a national campaign aimed at promoting pharmacy services (I only hope funding will be restored to community pharmacies in the near future). Self-Care awareness can only be increased through national and local campaigning and I'd like to see Lincs West CCG work with local NHS trusts to come up with more innovative social media campaigns so that patients are aware of what they can do to alleviate symptoms of conditions and when they should seek advice in as clear and concise a way as possible.I also understand that Skype consultations may be appropriate for some University of Lincoln, Bishop Grosseteste University and Lincoln College students who are tech savvy but ease of access to services must remain in place for students who'd rather get reassurance face-to-face.

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.