The place of walk-in clinics in healthcare systems

Walk-in clinics have existed in Canada since the late 1970s, but the evidence on who uses them and why, and their effectiveness and economic impact, is disconcertingly sparse. Of the nine primary studies cited in a review of walk-in clinics in Canada, published in this issue of the BMJ (p 928), six were surveys of patients attending walk-in clinics, emergency departments, or general practices; one was a review of the clinical records of patients attending an after hours clinic; one surveyed staff informants at walk-in clinics about organisational arrangements and services; and one compared the costs of treatment at walk-in clinics, general practices, and emergency departments using data on fee for service claims from a provincial health insurance plan.¹ All but two studies were based on a single walk-in or after hours clinic or on samples of patients drawn from one or a small number of general practices. Most studies provided data from the early 1990s or earlier and may not reflect current use.

The only economic evaluation that was identified concluded that the cost of care at walk-in clinics was similar to costs at general practices and that this was lower than costs at emergency departments.² Although this study has methodological limitations—including the potential misclassification of walk-in clinics, after hours clinics, and family practices; an unknown degree of diagnostic inaccuracy; and an inability to distinguish whether subsequent visits were for the same condition as the initial visit—the results are consistent with findings from the United States that costs are higher in emergency departments than in other primary care settings.³,⁴

There is a lack of evidence on the quality and effectiveness of the care provided in Canadian walk-in clinics as compared with other primary care settings; there is also no evidence of their impact on the overall utilisation of primary care services and the costs of primary health care. A recent study comparing quality, utilisation, costs, and satisfaction with care at walk-in clinics, emergency departments, and general practices in the province of Ontario will partially fill this gap (unpublished data). The controlled trials register of the Cochrane Library includes no studies on the effectiveness or efficiency of walk-in clinics.

In the absence of evidence, advocates of walk-in clinics claim that the clinics save “millions of dollars” for provincial healthcare plans by reducing the number of visits that patients make to emergency rooms; critics of walk-in clinics accuse them of providing “fragmented, intermittent care” because they fail to attend to preventive care, chronic disease management, and psychosocial issues.⁵

Walk-in clinics developed in Canada not from the deliberate policy decisions of provincial ministries of health but in response to the entrepreneurial opportunities offered by the public funding of physician's services through fee for service payments. Having played no part in their creation, ministries of health have remained on the sidelines, taking no policy initiatives to either discourage or encourage their proliferation.

In the absence of walk-in clinics the options available to the public are self care, care in an emergency department, or care by a general practitioner. People who decide to treat themselves or have to wait to be seen by a general practitioner may, along with their caregivers, experience varying degrees of worry. Theoretically, inappropriate self care or delayed care could cause morbidity that might have been avoided with timely treatment. Unfortunately, there is no evidence that the speedier access to care afforded by walk-in clinics reduces subsequent morbidity.

Presumably, policymakers would not want to establish walk-in clinics as substitutes for appropriate self care or care by general practitioners unless they placed a high premium on reducing anxiety. If policymakers wanted to encourage self care, they might look to public education interventions as an alternative to walk-in clinics.

Policymakers may, however, wish to divert care for acute minor conditions from emergency departments to other primary care settings, possibly including walk-in clinics and general practices. Before doing so they should consider what arrangements need to be in place in all three settings to encourage this shift while ensuring that patients' needs and reasonable expectations are met. Options might include developing policies that make access to general practice services easier both during and outside regular consulting hours; they might also include telephone triage and advice services staffed by nurses. Telephone services could relieve anxiety for many patients who either are treating themselves or waiting to see a general practitioner, and these might also be add-on services for the “worried well.”^6–8 What is needed, as in all policy initiatives, are clearly specified objectives; consideration of the effects that might occur elsewhere in the healthcare system and beyond; anticipation of the potential responses of stakeholders (especially, in the case of walk-in clinics, patients and general practitioners); and preplanned, adequately funded, and rigorous evaluation of innovations.

Papers p 928