HEALTH PROMOTION INTERVENTIONS IN WALK-IN CENTRES

Art & science The acute urgent synthesis care of art and science is lived by the nurse in the nursing act JOSEPHINE G PATERSON HEALTH PROMOTION INTERVENTIONS IN WALK-IN CENTRES The findings of an investigation into opportunities to talk with clients about smoking cessation, weight management and alcohol interventions Correspondence gimmyjaycaddy@aol.com Cindy U Chacha-Mannie is an emergency nurse practitioner, Minor Injuries and Illnesses Unit, St Mary s NHS Treatment Centre, Portsmouth, and a professional doctorate student at the school of health sciences and social work, University of Portsmouth Ann Dewey, interim associate head for research and innovation, School of Health Sciences and Social Work, University of Portsmouth Date of submission September 9 2015 Date of acceptance November 23 2015 Peer review This article has been subject to double-blind review and has been checked using antiplagiarism software Author guidelines journals.rcni.com/r/ phc-author-guidelines Abstract NHS walk-in centres (WICs) were opened in 2000 to modernise the NHS and increase accessibility to healthcare. They developed rapidly and are used successfully by the public. But little is known about the clients presenting and even less about health promotion and disease prevention strategies adopted by WICs. This review aims to explore, through client profiling, whether there is an opportunity for health promotion service delivery in WICs and minor injuries/illness units. The findings indicate that clients attending these units are similar in profile to those presenting to GPs and emergency departments, and that there is an opportunity to use these centres more effectively for health promotion. Keywords alcohol, health promotion, minor injury illness unit, nurse-led, nurse practitioners, obesity, primary care, public health, smoking, walk-in centres ABOUT 170,000 people die prematurely every year in England (Department of Health (DH) 2011) with more than 15.4 million people affected by long-term conditions, specifically heart disease, type 2 diabetes, cancers (particularly oral, lung, breast, gastric), some skin conditions, and circulatory and respiratory diseases, especially chronic obstructive pulmonary disease (DH 2010). These diseases have been linked to unhealthy lifestyle choices, specifically poor diet, inactivity, smoking, obesity and alcohol (DH 2010). The World Health Organization (WHO) (2014) states that Britain has the worst rate of obesity in Europe, with 63% of the population overweight and 27% obese. According to the Office for National Statistics (2012), 21% of the population are smokers and 27% consume alcohol on five or more days a week. Health promotion has traditionally fallen within the remit of GP surgeries, most of it provided by practice nurses (King s Fund 2010). Workload, pressure faced by GPs and emergency departments (EDs), the increase in the rate of non-accidental premature deaths and long-term conditions have raised the importance of disease prevention and health promotion across primary health care. As a consequence, the current public health agenda aims to bring radical changes in approaches to disease prevention, the delivery of services and increased access to primary care, making it everybody s business (Fenton 2013). The focus on public health, with reinforcement of the prevention of disease and promotion of health, is central to recent reforms (NHS England 2014). The new public health system, an integrated whole-system approach (DH 2013), requires local authorities to make every contact count. Steps should be taken to protect the health of the population by offering services such as tobacco control, tackling obesity, alcohol and drug misuse, and health checks. The responsibility of 18

19 Alamy

Art & science acute urgent care commissioning these services has been given to local government, clinical commissioning groups (CCGs) and the NHS Commissioning Board local teams in what is term a placed-based approach to public health (Fenton 2013). At a local level, in Portsmouth, the CCG is responsible for commissioning services at the Walk-in Centre (WIC) and Minor Injuries/Illness Unit (MIU). Back in 1999, when the DH proposed to open 20 pilot walk-in centres within six months, with a budget of 30 million, health promotion was one of the main drivers (DH 1999) (Table 1). Currently, while not much is being said about WICs or MIUs and health promotion directly, now that these services are commissioned by the CCG which collaborates on public health health promotion in WICs and MIUs is relevant again. The CCG will be held accountable for its activities, ensuring probity and improving local health outcomes (DH 2012). The local MIU will therefore need to meet the health promotion needs as set by the local CCG for the local MIU, and show evidence of how they are being met. A literature review (Chacha-Mannie 2014) concluded that the role of WICs and MIUs was not clear: there was lack of clarity in terms of structure (Jackson et al 2005), about services provided (Salisbury et al 2002), and about the educational and skill requirements of nurses working in these centres (Taylor 2008). The DH s rapid pace in moving from proposal to opening of these units was blamed for this situation (Chalder et al 2003. Table 1 Features of walk-in centres as defined by the Department of Health A patient/population needs assessment that supports the development of an innovative primary care centre and is sensitive to the age, culture and lifestyle of patients One of two accredited NHS Direct decision-support protocols for patient management and a clear commitment to provide a service to consistent national standards Effective management systems to predict and manage patient demand Skill mix that maximises the skills and experience of nurses and meets patient needs in the most cost-effective way Provision of a range of high quality minor ailment/treatment services and possibly medical minor injuries services to all patients Provision of information about the NHS, social services, and other local statutory and voluntary services Provision of information and advice about self-care, and healthy lifestyles, such as smoking and diet, which should be met by pilot sites (DH 2009) The review revealed that WICs and MIUs had increased access to health services (Pope et al 2005), as Anderson (2002) and Salisbury et al (2002) had found. Clients were satisfied with the level of care (Anderson 2002), and WICs were highly regarded by most of the patients who used them and by other healthcare providers (Pope et al 2005). Clients were satisfied because they felt nurses had listened to them and because there was anonymity (Chapman et al 2004). Grant et al (2002) commended WICs as offering a great opportunity for nurses to develop their autonomy and to use their skills. WICs and MIUs are mostly nurse-led (Monitor 2014), indicating that nurses working in them have a good deal of autonomy. Local health priorities The population of Portsmouth has been found to have poorer health compared to the average in the rest of England (Portsmouth City Council 2010). Levels of deprivation are generally worse than average (Public Health Observatory 2014). As one of the most densely populated cities in England outside London, Portsmouth has a high number of premature deaths, disabilities and generally poor health. Life expectancy is below the national average. It is 10.8 years lower for men and 6.1 years lower for women in the most deprived area compared with the least deprived, and there is an inequality gap and deprivation that has led to poverty in most areas (Public Health Observatory 2012). However, 62% of the city s population are aged between 20 and 64, so it has a high percentage of potentially working population. While there have been health improvements, Portsmouth continues to perform low on key outcomes including smoking, alcohol-related admissions, and obesity among adults and children (Portsmouth CCG 2014). Similar to the rest of England, leading causes of non-accidental premature deaths in Portsmouth are heart disease and cancer. The high rates of poor health, poverty and deprivation are attributed to poor lifestyle choices, specifically smoking, alcohol and drug misuse, obesity and poor diet, as well as poor access to health services and lack of education (Public Health Observatory 2012). Estimated levels of adult healthy eating and physical activity are lower than England s average. There are more smokers in Portsmouth compared to the average in England, and this is the main reason for lower life expectancy in the city (Health Profiles 2014). A local CCG report (Portsmouth CCG 2014) classes 52% of Portsmouth s population as obese. Figures published by Health Profiles showed that 24% of the adult population in Portsmouth consumed alcohol at levels that could 20

harm their health compared to an average of 22% elsewhere in England; 22% of those over the age of 16 were defined as binge drinkers and 8% drank at higher-risk levels (Health Profiles 2014). Priorities for Portsmouth City Council s wellbeing service (Portsmouth CCG 2014) include reducing obesity, physical activity, better nutrition, and tackling alcohol and smoking. Portsmouth s MIU aspired to make a difference and contribute to the improvement of the public health of Portsmouth by integrating health promotion into services provided to clients presenting for illnesses and injuries. In a city with a high rate of poor health, making sure that every contact counts for every presenting client, is a priority. In the ten years that the MIU in Portsmouth has been open, health promotion has not been a priority. The aim The aim of the study was to explore the kind of clients that present to MIUs and WICs to establish whether there is a high-risk population (smokers, people who are obese and/or overuse alcohol) and whether there is a necessity and opportunity for health promotion services. Literature review A number of databases were used to search for literature on health promotion in MIUs and WICs including CINAHL, EBSCO, PubMed and others. Boolean operators and MeSH terms including WIC, MIU, Health Promotion, Smoking, Weight, Alcohol and similar were used. There was only one study found on health promotion in WICs/MIUs, with Salisbury (2003) merely stating that WIC s have a role in health promotion, some run courses to support people wanting to give up smoking or lose weight, with no other explanation or elaboration. The only relevant paper was by Patton and Vohra (2013), titled Hazardous drinking in patients attending a minor injuries unit: a pilot study. This found that of the 70% of clients who presented to emergency departments (EDs) with hazardous drinking, 20% were classified as experiencing minor injuries and should more appropriately have been seen in MIUs by emergency nurse practitioners, who are more likely than doctors to offer health-related advice and information. Participants were included in the study if they attended the MIU near a major London hospital, were over 16, English-speaking and consumed daily at least double the number of units recommended by the DH or if they admitted to alcohol-related MIU presentation. Data were collected over four weeks on age, gender, reason for attendance and previous attendance at an ED. After interaction with 1,000 clients who presented during the study period, 315 were approached and 192 consented to take part in the study. Paddington alcohol test screening was conducted with written advice. Only 3% of the identified 36% hazardous drinkers accepted the offer of help or advice. Patton and Vohra (2013) concluded that few participants who could have benefited from help and advice accepted such an offer as they did not associate attendance with their drinking. Because there is limited health promotion in WICs and MIUs, literature was sought that explored the implementation of health promotion services in similar organisations; in this case EDs, which are similar in that they have four-hour targets, are not paid for health promotion activity and see clients/ patients in one-off encounters (Monitor 2014). A randomised controlled trial on a multi-component smoking-cessation strategy in ED by Bernstein et al (2011) found few published clinical trial interventions in ED for smoking. The 338 participants in their study were patients from a low socio-economic group who were contemplating quitting smoking. The study concluded that smoking-cessation intervention is feasible in EDs but physicians require training to use teachable moments and to incorporate services into practice. A US literature review by Woolard et al (2011) on brief motivational alcohol intervention in ED explored the FRAMES model (feedback, responsibility, advice, menu or choice, empathy and self-efficacy) of brief motivational intervention and negotiation interviewing, which takes about 20 to 30 minutes. The review concluded that progress was made in ED in meeting public health goals of reducing alcohol misuse. The authors observed that the ED is an important setting for initiating a teachable-moment brief intervention, but it has to form part of routine care. More than 50% of the reviewed studies involved nurses. The similarities between the studies were that the nurses were positive about recommendations to implement health promotion in their settings. But it was observed that although they were positive, there appeared to be common barriers to the implementation of health promotion. The barriers were time, education, training and management support (Cross 2005). Cross (2005) conducted a qualitative study of ED nurses attitudes towards health promotion and found little research on health promotion and nurses who work in EDs. Similar findings were identified by Bensberg et al (2003) in direct interviews with nurses about opportunities for health promotion 21

Art & science acute urgent care 22 in EDs. The researchers concluded there was little literature on how to integrate health promotion into the organisational structure of EDs and that ED staff are not educated in health promotion. The barriers identified were similar to those found by Cross (2005). No studies were found on weight management in EDs, WICs or MIUs. The government s focus on public health has highlighted health education and health promotion as imperative in primary care. The WHO has clearly defined primary health care guidelines, including advice and strategies on the promotion of health and prevention of disease (WHO 2014). However, there is a lack of evidence that these guidelines and the DH s WIC key features (DH 1999) are being delivered, nor is there enough published research on health promotion in these centres. The gaps in the literature raise a number of questions. Is health promotion being offered at WICs and MIUs? Is there a need for these services? Would presenting clients benefit from them? Who are the clients presenting to these centres? Would there be any benefit in implementing health promotion at our local MIU? There is a need to evaluate how health promotion is implemented in WICs and to establish whether clients presenting at WICs and MIUs would benefit from health promotion services. This need is underpinned by demand for healthcare services and a need to target health and wellbeing issues, especially in Portsmouth, where the researcher is based and where the health of people is poor compared to the rest of the country (Public Health Observatory 2014). The local MIU The local MIU is centrally located in Portsmouth, accessible to clients by walking, or by public or private transport, and sees more than 3,300 clients a month of all ages. The unit is nurse-led with a minimum of two nurses in the morning (7:30-10am), five nurses in the middle shift (10am-6pm) and three in the evening (6-10pm). It is open daily from 7.30 or 8am over the weekend and bank holidays to 10pm. The nurses have wide knowledge, skill mix and experience and come from various backgrounds including emergency care, primary health care and orthopaedics. Recently, paramedic practitioners have been employed (Care UK undated). Ethical approval A doctorate research proposal was successfully submitted to the University of Portsmouth s school of health sciences and social work to implement health promotion services (smoking cessation, weight management and alcohol intervention) at the local WIC for minor injuries and illness. The proposal was peer-reviewed at the University of Portsmouth. NHS ethical approval was gained via the Integrated Research Application System (IRAS), in June 2015 and clinical governance was approved by the local CCG and Care UK. Methodology Phase I of the study aimed to develop a presenting client/patient data profile to determine whether there was a need for health promotion and a need for one, two or all three of the identified health promotion strategies. Data collection ran from July 1-31 2015. The mandatory booking-in form for all clients was adapted to include smoking status (including e-cigarettes and occasional smokers), weight, height, and alcohol consumption per week. Rethink your drink alcohol scratch cards were used to help with the identification and assessment of alcohol consumption (Drink Sense 2014). A request to use data for research purposes was included in the booking-in form with a simple yes or no tick-answer. Inclusion criteria were all clients aged between 16 and 75. All nurse practitioners were trained and requested to screen all clients in this age group. Anonymous data were collected from the booking-in form and captured in Microsoft Excel. Holidaymakers, people experiencing mental ill health, and emergencies including cardiac chest pain, severe acute illnesses and others were excluded. All Excel spreadsheets were exported daily onto IBM SPSS version 22 for data cleansing and analysis. Simple descriptive analysis was undertaken on SPSS, specifically breakdown of age group and gender. Cumulative analysis of smoking, body mass index (BMI) and alcohol intake in units was performed. Clients were classed as overweight or obese if their BMI was 26 or over. A total of 4,025 clients presented in July 2015 (Table 2). Among the target group for the study (n=2,818), 1,385 (49%) were male and 1,433 (51%) female (Table 3). Table 2 Ages of presenting clients Results Age Total 0-15 970 16-75 2,818 76+ 237 Total 4,025

Clients presented with a diverse group of complaints ranging from simple cuts, fractures, sprains, skin conditions, motor vehicle accident injuries, eye injuries, minor infections and many more, including alcohol-related injuries. High risk screening was done by asking for smoking status including occasional smokers and smokers of e-cigarettes. Clients were asked about their weight and height, used to calculate BMI, and about their alcohol consumption per week (Table 3). Discussion The presenting clients were similar to those who present to GP surgeries and EDs. It is well documented that GPs are paid to provide health promotion services (NHS England 2014), but there are questions about how a ten-minute appointment can cover the presenting medical complaint, its management and health promotion interventions. Studies have been undertaken into extending surgery opening hours and consultation times, but they refer to addressing complex medical issues and not the inclusion of health promotion during consultation (Oxtoby 2015). The findings are similar to those of Peckham and Exworthy (2003), who observed that GPs continue to practise a medicalised system of primary care and emphasise treatment over prevention of disease and promotion of health. However, GP services were not the focus of this study, which is investigating the potential of nurse-led services. If more than 2,800 clients are presenting to an MIU per month, there are health promotion opportunities that have to be explored. A number of services can be promoted, including chlamydia screening and teenage pregnancy, but the focus of this study was confined to smoking cessation, weight management and alcohol intervention. With an awareness of the high levels of smoking, obesity and high alcohol intake shown in the snapshot of clients presenting to the Portsmouth MIU in this study, it can be argued that practitioners should take every opportunity presented to engage clients and make every contact count in their consultations, with the aim of improving lifestyles and reducing inequality. Lessons learned as a result of the study are summarised in Table 4. Conclusion A high number of clients present with unhealthier lifestyle behaviours to the local MIU: 70% of the presenting clients were found to have higher risk behaviour through smoking, alcohol abuse, being overweight/obese or a combination of these. This figure is consistent with the figures in the city; the Wellbeing Service observed that 70% Table 3 High-risk status of clients Daily attendances Male Female Smokers BMI 25 and over Alcohol: more than 26 units 2,818 1,385 1,430 784 (28%) 1,683 (60%) 135 (5%) Table 4 Lessons learned What is already known about walk-in NHS WICs were introduced in 2000 WICs expanded rapidly There is lack of clarity in terms of services and roles in these units for health promotion or for nurses WICs have high attendances and patient satisfaction Health promotion was a key feature of initial WIC proposals but there is no clear indication of its implementation There are high rates of premature deaths and long-term conditions in the UK and in the locality What this study adds WICs see similar patients to those in GP surgeries and EDs Minimal literature is available on health promotion service delivery in WICs and MIUs Pilot studies in alcohol prevention and smoking cessation have been successful in EDs Obesity is widespread in the UK, but there is limited literature on management in MIU/WICs The patient profile suggests a need for health promotion interventions in WICs and MIUs Based on the high numbers of unhealthy lifestyle choices (Table 3), there is an opportunity for practitioners in these centres to provide brief health promotion and MECC (making every contact count) to improve healthier lifestyle choices longer healthier lives 23

Art & science urgent care of the city s population engage in two or more unhealthy behaviours (Portsmouth City Council 2016). Strategies to improve health have been re-enforced to include brief health promotion interventions and Making Every Contact Count (MECC). MECC encourages all care professionals to use every opportunity to empower healthier lifestyle choices ranging from brief advice on smoking, weight, alcohol and healthy eating (MECC 2012). Practitioners in these centres also have the opportunity of implementing MECC in their units. WICs have been proven to increase access, they are successfully managed by nurses and are widely used by clients/patients. There is, however, no clarity in terms of their role and services. It would appear that services are dependent on the commissioning body. The local MIU services are commissioned by the CCG and there is subsequently a duty to provide health promotion and health education. In terms of public health provision, the onset of long-term conditions may be delayed by minor lifestyle changes such as smoking cessation, a reduction in alcohol intake, healthy balanced diets and exercise. These can be achieved through education, health promotion and by providing information that should be available at the first point of contact and at the primary care stage to enable individuals to look after their health and that of their families (WHO 2012). For various reasons outside the scope of this study clients present to MIUs and WICs as their first point of call, so health promotion opportunities must be taken as a means of contributing to holistic care. Proposal for next phase Involve management in integrating health promotion in service delivery. Train emergency nurse practitioners to make health promotion part of every client contact. Conduct further studies to explore the best time for, approach to and effectiveness of implementing health promotion during the client s presentation in the MIU. Conduct interviews with nurses about their experiences and perspectives of health promotion in MIUs. Collect data from service users/clients/patients on their views of health promotion in MIUs. Online archive For related information, visit our online archive and search using the keywords Conflict of interest None declared References Anderson E (2002) NHS walk in centres and the expanding role of primary care nurse. Nursing Times. 98, 19, 36. Bensberg M, Kennedy M, Bennetts S (2003) Identifying the opportunities for health promoting emergency departments. Accident and Emergency Nursing. 11, 3, 173-181. Bernstein S, Bijur P, Cooperman N et al (2011) A randomised trial of multicomponent cessation strategy for emergency department smokers. Academic Emergency Medicine. 18, 6. Care UK (undated) Minor Injuries/Illnesses at St Mary s NHS Treatment Centre. tinyurl.com/ zg2wg63 (Last accessed: February 11 2016.) Chacha-Mannie C (2014) Health promotion in NHS walk in centres: a literature review. Primary Health Care. 24, 5, 24-28. Chalder M, Sharp D, Moore L et al (2003) Impact of NHS Walk in Centres on the workload of other healthcare providers: a time series analysis. British Medical Journal. 326, 7388, 532. doi:dx.doi.org/10.1136/bmj.326.7388.532. Chapman J, Zechel A, Carter Y et al (2004) Systematic review of recent innovations in service provision to improve access to primary care. British Journal of General Practice. 54, 502, 374-381. Cross R (2005) Accident and emergency nurses attitudes towards health promotion. Journal of Advanced Nursing. 51, 5, 474-483. Department of Health (1999) NHS Primary Care Walk-in Centres Selection of Pilot Sites for 1999/2000. tinyurl.com/zcvw7n2 (Last accessed: April 15 2016.) Department of Health (2010) Healthy Lives, Healthy People: Our Strategy for Public Health in England. The Stationery Office, London. Department of Health (2011) Ten Things you Need to Know about Long Term Conditions. tinyurl.com/z6bj7dj (Last accessed: April 15 2016.) Department of Health (2012) Accounting Officer System Statement. DH, London. Department of Health (2013) Improving Outcomes and Supporting Transparency. tinyurl.com/pzc3gnr (Last accessed: April 15 2016.) Drink Sense (2014) Rethink Your Drink. tinyurl. com/gmfx5md (Last accessed: April 15 2016.) Fenton K (2013). Making Health Everybody s Business. Public Health England. tinyurl.com/ ze2x8yz (Last accessed: April 15 2016.) Grant C, Nicholas R, Moore L et al (2002) An observational study comparing quality of care in walk-in centres with general practice and NHS Direct using standardised patients. British Medical Journal. 324, 7353, 1556. Jackson C, Dixon-Woods M, Hsu R et al (2005) A qualitative study of choosing and using an NHS walk-in centre. Family Practice. 22, 3, 269-274. King s Fund (2010) A Pro-active Approach. Health Promotion and Ill-health Prevention. King s Fund, London. Making Every Contact Count (2012) MECC in Action. www.makingeverycontactcount.co.uk (Last accessed: April 8 2016.) Monitor (2014) Walk-in Centre Review: Final Report and Recommendations. Monitor, London. NHS England (2014) Five Year Forward View. tinyurl.com/zgjzj5u (Last accessed: April 15 2016.) NHS England (2014) NHS England Standard General Medical Services Contract. tinyurl.com/ z7crtxx (Last accessed: February 11 2016.) Office for National Statistics (2012) Drinking Habits Amongst Adults, 2012. www.ons.gov.uk/ ons/dcp171778_338863.pdf (Last accessed: February 11 2016.) Oxtoby K (2010) Consultation Times. tinyurl. com/zcfd4n8 (Last accessed: February 11 2016.) Patton R, Vohra M (2013) Hazardous drinking among patients attending a minor injuries unit: a pilot study. Emergency Medicine Journal. 30, 1, 72-73. Peckham S, Exworthy M (2003) Primary Care in the UK: Policy, Organisation and Management. Palgrave Macmillan, Basingstoke. Pope C, Chalder M, Moore L et al (2005) What do other local providers think of NHS walk-in centres? Results of a postal survey. Public Health. 119, 1, 39-44. Portsmouth City Council (2010) Joint Strategic Needs Assessment. tinyurl.com/hxuaprg (Last accessed: February 11 2016.) Portsmouth City Council (2016) Portsmouth Wellbeing Service. tinyurl.com/jbgwwfw (Last accessed: April 8 2016.) Portsmouth Clinical Commissioning Group and Portsmouth City Council (2014) Joint Health and Wellbeing Strategy: Working Better Together to Improve Health and Wellbeing in Portsmouth 2014-2017. tinyurl.com/zcs3j3a (Last accessed: February 11 2016.) Public Health Observatory (2012) Portsmouth Health Profile 2012. tinyurl.com/hyo9nlu Public Health Observatory (2014) Portsmouth Health Profile 2014. tinyurl.com/zrjdzuw (Last accessed: February 11 2016.) Salisbury C (2003) Do NHS walk in centres in England provide a model of integrated care? International Journal of Integrated Care. Jul-Sept 3, e18. Salisbury C, Chalder M, Manku-Scott T et al (2002) What is the role of walk-in centres in the NHS? British Medical Journal. 324, 7334, 399-402. Taylor J (2008) The rise of the walk in centre. Nursing Times. 104, 33, 16-18. Woolard R, Cherpitel C, Thompson K (2011) Brief intervention for emergency department patients with alcohol misuse: implications for current practice. Alcohol Treatment Quarterly. 29, 2, 146-157. World Health Organization (2012) Health Promotion. WHO, Geneva. tinyurl.com/qa9z8xv (Last accessed: February 11 2016.) World Health Organization (2014) United Kingdom Non-Communicable Diseases. WHO, Geneva. tinyurl.com/jjkf9ay (Last accessed: February 11 2016.) 24