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Are we increasing choice or adding confusion?

Marilyn Eveleigh
Consultant editor

The NHS is undergoing relentless and resonating transformations to meet the needs of a changing society. Yet society is not particularly grateful for the NHS - after all, they have paid for it. Indeed, we are becoming increasingly vociferous in what we want of the NHS, where we want it provided, and when we want it. Access to healthcare services is a prime example.

Healthcare has traditionally been provided by the GP surgery, which covered all hours for registered patients. But this is no longer good enough. Changes in GP working contracts, increased demands for appointments, combined with raised patient expectations and mobility has led to a change in NHS culture - to one that gives patients a choice.

Now there is an array of alternatives that patients are encouraged to access, day or night: telephone NHS Direct first; try for a GP appointment; go to a walk-in centre, or an urgent care centre, or a minor illness centre, or a minor injury unit; try the GP out-of-hours service for evenings and weekends; and there are always the traditional accident and emergency (A&E) departments attached to major hospitals. What a choice!

But how do patients make the choice of where to attend? What are the differences in care provided by the different units? Do patients know this beforehand or take pot luck and risk being referred elsewhere? Or is the deciding factor simply the opening times? Not having to make an appointment suits some of the population.

Emerging studies are now highlighting public confusion around the care offered by the various models, especially walk-in centres. A Bristol study of 700 patients attending eight A&E centres and eight walk-in centres found that 80% had been redirected from an A&E centre to a walk-in centre. Most people had chosen to go to the A&E centre, even when there was a walk-in centre in the hospital grounds. A third of those treated in the walk-in centres would have preferred to be treated in A&E.

My experience of the new healthcare options is that they are very variable - names do not describe or guarantee the same service. Some have doctors, some are nurse-led; some have additional staff such as mental health specialists or access to social workers and health visitors; some use PGDs for supply of medication, while others employ independent prescribers; some X-ray and set fractures, others do not; some will advise on or treat coughs, colds and sore throats, others will refer back to the GP surgery. I admit - I'm confused. If I'm part of the NHS family and I'm not clear what service is behind the name, why should we expect patients to be certain?

Does this matter if patients get a better service? Increasing patient choice, cutting waiting times and improving patient satisfaction are factored in when designing new services, but evidence suggests that these have not necessarily been achieved. A Sheffield University study has shown that walk-in centres do not decrease GP practice workloads - patients still have long waits, especially in the most deprived areas.

There is a call for clarity on what walk-in centres offer, then their success could be accurately measured. The variability and titles of alternative centres may not always be in the public's best interest if they cannot make informed decisions on when and where to go for their health needs. Clinicians also need to be clear - we are human signposts in the new NHS.