Nurse-led National Health Service walk-in centres are appearing in a variety of settings and locations across England as part of the Government's plan to broaden access to primary care. The services they offer have much in common with community pharmacy. Pamela Mason visited two centres in west London that have a pharmacist as their project manager
National Health Service walk-in centres are part of the new NHS furniture and with 36 sites planned and 21 currently open, many pharmacies may have one nearby. One of a range of Government initiatives aimed to modernise and improve access to NHS services, the centres are part of the primary care system, and nurse-led, where people can get advice and treatment for minor illnesses and minor injuries without an appointment. Funded through the Government's modernisation fund, many are open from early morning to late evening, seven days a week.
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The reception and waiting area at the Parson's Green NHS walk-in centre |
The centres are sited in a variety of locations, including supermarkets or other retail areas, residential districts or alongside accident and emergency (A&E) departments. The first one opened in Soho in January this year.
One centre, yet to open, will be based in purpose-built health care facilities at Manchester airport. It will serve the population that passes through the airport to other destinations and also the staff who work at the airport. In addition to the services offered by other centres, this walk-in centre will also focus on advice about travel health.
Another centre is based in a health centre next to a supermarket in Norwich, while Peterborough has a centre on the high street near the market and Newcastle upon Tyne's centre is located next to the A&E and minor injuries unit at Newcastle General hospital. Royal Hallamshire hospital is the location for a centre in Sheffield, on a site for which there are also plans for a 24-hour community pharmacy and dental clinic.
The centres are managed by project steering groups with representation usually from, the local primary care groups (PCGs), health authorities, hospital and community health care trusts, emergency medical services and NHS Direct. All the centres are nurse-led, but the precise skill mix reflects local needs, and may include general practitioners, social services staff and other health care professionals.
Two walk-in centres, which I visited recently, in Fulham, west London, are unique in that the project manager for the centres is a pharmacist. Qualified for 10 years, Mr David Tamby Rajah has a community pharmacy background, from which he gained a growing interest in primary care, health care resources and business management and analysis. The post attracted him because he believes that walk-in centres can make a real difference to health care in the United Kingdom. He also relished the thought of a new intellectual challenge, of which there has clearly been no shortage since he started four months ago.
With his pharmaceutical background, Mr Tamby Rajah brings unique expertise to the job, in that he can provide the nurses who work in the centres with an awareness of community pharmacy - and what pharmacists do - as well as training in pharmacology. His pharmacy management skills are used in a variety of areas such as analysis of staffing needs, stock control and making best use of space. The ability to be a fast decision-maker and forge links with the movers and shakers to help fulfil the service is also a vital skill which he feels his community pharmacy experience gave him. And having ongoing links with the Royal Pharmaceutical Society, the local pharmaceutical committee (LPC), the National Pharmaceutical Association and the Pharmaceutical Services Negotiating Committee - and the fact that he works occasionally as a locum - helps to keep him in touch with the profession.
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Left, the entrance to the Parson's Green NHS walk-in centre; centre, David Tamby Rajah with nurse practitioner Anne Olaitan; right, Christine Glover with David Tamby Rajah during her visit to the Parson's Green centre |
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The Fulham walk-in centres are based at two sites with a telemedicine link between them. One centre is at Parson's Green, next to the Riverside community healthcare trust, and the other is based at Charing Cross hospital, adjacent to the accident and emergency department. Both walk-in centres were formerly nurse-led minor treatment centres and had a history of collaborative working with community pharmacies, Mr Tamby Rajah says.
The centres are a joint venture partnership with representation from both primary and secondary care, including Fulham PCG, Riverside community healthcare NHS trust, Hammersmith Hospitals trust and NHS Direct. A lack of representation from community pharmacy has been addressed by the appointment of a project manager who is a pharmacist.
Because of the areas they are in, the two centres have quite different clienteles. Leafy, suburban Parson's Green attracts a high proportion of its patients from the local residents, who have either not yet registered with a GP or who cannot get to see their GP, and about 40 per cent of the patients are referred by local GP practices. By contrast, nearly half the patients at Charing Cross are referred by A&E and only 15 per cent by GPs. The number of patients at both centres is gradually increasing, with Parson's Green currently seeing about 1,400 patients a month, and Charing Cross about 1,000.
The nurses keep records as appropriate - in Fulham, these are currently paper based, but will eventually be computerised - and, with the patient's permission, these are sent to the GP if the nurse thinks this is necessary.
The nurses who work in the centres are nurse practitioners from a variety of nursing backgrounds, including accident and emergency, health visiting, district nursing, mental health nursing and primary care. Not many of such nurses are available, but this level of experience is required to deal with the varied case mix that presents at the walk-in centres, Mr Tamby Rajah points out.
To cover the opening hours, the nurses work in rotation. During the week, there are always three on duty at the Parson's Green centre and three at Charing Cross. All the nurses work autonomously, in accordance with local protocols.
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Left, nurse team leader Kate Harding examines a patient's ear at the Parson's Green walk-in centre; right, at the Charing Cross walk-in centre, nurse practitioner Wendy Cunningham dresses a patient's injured arm |
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Patients are offered face-to-face care and advice in NHS walk-in centres. This is in contrast to NHS Direct, which offers advice and information on the telephone. Indeed, NHS Direct nurses may refer callers to walk-in centres. In addition, many walk-in centres will eventually have an on-line NHS Direct access point on the premises. In parts of Fulham, however, NHS Direct is not yet operational, and in addition to their other services, the walk-in centres are currently filling that gap. One of the other differences between NHS Direct and NHS walk-in centres is that NHS Direct offers a more standardised, top-down approach, while walk-in centre services will be allowed to develop locally in response to their case mix.
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Comparison between walk-in centres and community pharmacies
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In addition to these core services, NHS walk-in centres can supply medicines (PJ, February 19, p282). Because the centres are part of the NHS, the system of medicine supply is similar to that for hospital outpatients, using protocols that comply with the recommendation of the review of prescribing, supply and administration of medicines (the Crown review). In Fulham, about 30 different medicines are supplied, most of which are prescription only medicines. However, according to Mr Tamby Rajah, the nurses in Fulham issue at most only one or two medicines a day.
"We do not provide medicines for children under 16, there is no repeat prescription service and we do not supply additional P [pharmacy] or GSL [general sale list] items," Mr Tamby Rajah adds. "Supply of medication is not a significant part of our service. It's not a threat to community pharmacy, and if I had thought it was, I would never have taken the job in the first place."
Nurses who hold a district nurse or health visitor qualification are allowed to issue NHS prescriptions for products included in the Nurse Prescribers' Formulary. At present, the Fulham nurses do not write prescriptions, but Mr Tamby Rajah says this will happen in the future: "This will be another source of prescriptions for community pharmacists."
Mr Tamby Rajah believes that there are many opportunities for joint working between community pharmacy and walk-in centres. "Walk-in centres offer another opportunity for community pharmacists to work with yet another health professional," he says.
On her recent visit to the Fulham centres, Mrs Glover recognised the value of employing a pharmacist as manager - someone "who understands the importance of linking in with the local pharmacists and working together."
According to Mr Tamby Rajah, there has been no involvement of community pharmacies in the development of any other walk-in centre. "As a profession," he says, "we should be in a position to help and contribute to their development." He suggests several ways by which this could happen:
"The process has to be two-way, with joint training," he says. "It is important for community pharmacists to understand about walk-in centres and the services they provide and for the walk-in centre staff to know about community pharmacy."
As a start, Mr Tamby Rajah recommends that community pharmacists visit their nearest walk-in centre and find out what the nurse practitioners do. There could then be exploration of training to support the nurses in their knowledge of pharmacology and the role of community pharmacists. This could then lead on to joint working to promote self-care, development of local guidelines for health promotion, referrals and so on.
"This will help to break down barriers and misconceptions and form strong collaborative links which will result in good seamless care for patients. But at present there needs to be much more work on appropriate two-way referral of patients between the two services."
Walk-in centres and the role of the nurse practitioners in these centres are still in the early days of development. All the centres opened so far are pilots, and everything they do is subject to change. "The main aim at present is to get the service settled in and bonded with general practice and to find out what the centres actually do and what the demand is."
The new service is being evaluated nationally by Bristol university, and more locally an MSc pharmacy project at King's College London, being completed by Philippa Ahad, is looking at the interaction between walk-in centres and pharmacy.
Whatever pharmacists may think about walk-in centres, it is worth remembering the words of the President: "Every pharmacy is already a walk-in health centre. We need to ensure greater consistency of quality and we need to remind the public about what an asset their local pharmacy is."
Pamela Mason is a pharmacist and freelance writer from South London