By Cristina Brooks
Women, minorities and the homeless are likely to be the most affected by the conservative government’s plan to replace walk-in centres with services that may merge them with overcrowded and underfunded A&E services.
Hospitals and commissioners have been asked to reform all A&Es and walk-in centres in England by October 2017.[1]
NHS England says reforms are needed because many A&E queues exceed the NHS’s target of four hours, threatening the lives of patients.
People in lower socio-economic groups tend to be the most common users of walk-in centres.
Women disproportionately attend walk-in clinics, making up almost three-fifths of attendees, according to a 2013 survey by semi-autonomous government body Monitor. [2]
Nearly a quarter of all attendances was on behalf of a child.
Some walk-in centres care for high proportions of black, Asian, and minority ethnic populations.
This is unsurprising given many walk-in centres were specifically created to improve access to health care for vulnerable and minority groups, for example patients who said they could not book GP appointments.
Labour’s Equitable Access to Primary Medical Care policy aimed to create new walk-in-type health centres, dubbed “Darzi centres”, to tackle inequality in access to health care in 2008.
For example, Darzi centres were required to offer translations in order to serve patients who couldn’t understand English.
A Central London Community Healthcare NHS Trust (CLCH) study in 2013 found walk-in centres had improved access to care for black and ethnic minority patients.[3]
Darzi centres were also required to serve asylum seekers, refugees, substance abusers, the unemployed and the homeless.
Worcester Walk-in Centre, now closed, had previously treated at least 100 homeless patients.
More walk-in centres are being closed, despite the fact that this could reverse equality gains, according to the Monitor study.
Most recently, walk-in centres have been targeted by NHS-England-and-NHS-Improvement-led cost cutting efforts.
Health care commissioners and hospitals are being spurred to both improve service and cut costs, with NHS Improvement conditionally offering trusts part of the Sustainability and Transformation Fund( STF) a government grant delivered over two years. The funds are mostly going to cash-strapped A&E departments.
Trusts and their hospitals get the bulk of the money on condition they successfully cut costs by a target amount set by the government-led bodies[4]. [5] [6] [7] The overwhelming majority of trusts in England have accepted these targets.
Instructions for the plans being used to cut costs (STPs) tell hospitals they should integrate walk-in centres, GPs and A&E.[8]
These reforms, which NHS England is now mandating, were originally described in a 2013 review of A&E services by the current National Medical Director for NHS England, Sir Bruce Keogh.[9] This pre-dates the worst of the A&E crisis by several years, a fact that may give us pause.
NHS England has said it expects in the next two years 150 “integrated” urgent treatment centres will open and offer appointments that are bookable through 111 or GP referral.
Such urgent treatment centres will have comparable hours to walk-in clinics and will be staffed by GPs, other types of doctors and nurses, reported INews.
But these centres may not necessarily replicate the gains in access to health care walk-in centres have made for vulnerable and minority groups.
If queues for urgent treatment centre services are merged with overcrowded A&E ward queues, it logically follows that those walk-in centre-type services may not be as easy to access.
Future commissioning guidance will decide for certain whether urgent treatment centres will let patients “walk-in” or merely make phone-bookable appointments.
This could present barriers for those without phones or home addresses.
Other questions remain regarding the feasibility of the government’s strategy for the new facilities.
Siva Anandaciva, Chief Analyst at The King’s Fund called the plan “ambitious” and asked whether there would be enough staff available.
He said: “Although hospitals are being given some time to develop and roll out these new ways of working, they are still expected to achieve their A&E waiting times targets, which many have been failing to do for some time. It is an ambitious request to expect hospitals to both sustain existing services and develop new services in the period of a few months.
“There is still a finite number of GPs and it is unclear whether enough GPs will be available to staff these new hospital-based facilities, and what the ultimate impact of an en masse move of GPs towards hospitals from their current practice locations would be. “
A select committee reviewing health care spending warned that if hospital cuts couldn’t be made, there could be implications for patient care.
It expressed “grave doubts” over whether hospitals could afford new “integrated care” facilities given that most of the STF funding was going to cover hospital debts.
NHS Improvement is holding out the “carrot” of STF funding at the same moment hospitals are dealing with the “stick” of debt.
Nearly every hospital in England was in debt last year, or 131 of 138 hospital trusts, according to the BBC.[10]
- This is partly because the NHS has been starved of funding. Funding from 2010-2015 was less than the amount required to meet the growth in demand for NHS services, not least thanks to an aging and growing population, according to charity The Health Foundation.
- Across the NHS staff numbers had fallen, and hiring expensive temporary staff had risen, leading to growing debt.
- Certain trusts had been financially weakened by taking out capital loans through bodies that charge outrageous fees, called Private Finance Initiatives.
Just as the conservative government has not addressed critical financial and staffing issues with these A&E reforms, it seems to be putting very little effort into maintaining equal access to care for Britain’s most vulnerable.
[1] https://www.england.nhs.uk/statistics/wp-content/uploads/sites/2/2017/03/urgent-emergency-care-letter-09-03-17.pdf
[2]https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/283778/WalkInCentreFinalReportFeb14.pdf
[3]http://www.clch.nhs.uk/media/122378/patient_equality_data_report_2013_january.pdf
[5] Page 18 https://www.england.nhs.uk/wp-content/uploads/2016/07/strength-fincl-perfrmnc-accntblty-2016-17.pdf
[6] Page 30 https://improvement.nhs.uk/uploads/documents/STF_and_Financial_CT_1718_1819_Guidance_Indicative.pdf
[7] Page 56 https://www.england.nhs.uk/wp-content/uploads/2016/07/strength-fincl-perfrmnc-accntblty-2016-17.pdf
[8] https://www.england.nhs.uk/wp-content/uploads/2016/05/stp-aide-memoire-new-care-models.pdf
[9] https://www.england.nhs.uk/about/whos-who/
[10] http://www.bbc.co.uk/news/health-35608992
