Walking Canada's way

Canada, home to maple trees, the Toronto Blue Jays, and lip-licking doughnuts, provides glimpses of its pioneering work in this week's BMJ. A hundred years ago, when Canada was still a British dominion, the Canadian parliament “passed a measure forbidding the importation, manufacture, and sale of cigarettes.” It was an example that anti-tobacco campaigners in other countries hoped to take up (p 542).

More than 20 years ago Canada introduced walk-in health centres, a change driven by public funding of physicians' services through fee for service payments (BMJ 2000;321:909). By 2000 the NHS followed, despite limited evidence about the effectiveness and economic impact of these centres. Last year we published a study that used standardised patients to compare the quality of care available at walk-in centres with that provided by general practices and NHS Direct (2002;324:1556). Chris Salisbury and his team concluded that walk-in centres compared favourably but that the impact on referral to other healthcare providers needed examining. General practitioners were concerned that these centres would be a source of additional referrals. One miffed BMJ reader wrote: “The conclusion might be that walk-in clinics do a limited range of easy things adequately but refer more than is needed.”

Two of this week's papers examine this issue. Ronald Hsu and colleagues studied English towns and discovered that the walk-in centre had no effect on emergency general practice referrals, routine appointments, or out of hours demand (p 530). Attendance at the local minor injuries unit increased, but the researchers wisely conclude that this may be because the walk-in centre is in the same building. Another study, from Salisbury's group, hints that walk-in centres may even reduce doctors' workload, although the drop in consultations at emergency departments and general practices within a 3 km radius was not significant (p 532). Both teams report that walk-in centres are well used, indicating that they “have a role in satisfying particular needs for primary care services.” But it is too early to know how, in the long term, patients will use these centres or what impact they will have.

The rest of the world is scrambling to follow Canada's lead on revalidation and appraisal methods. Alberta assesses surgical practice by using feedback from medical colleagues, coworkers, and patients (p 546). Claudio Violato's team argues that this system assesses key competencies such as communication and interpersonal skills and that it provokes contemplation and initiation of change in surgeons.

The BMJ would be pleased to see the same effect in surgeons, and this week we might. Ani Anyanwu and Tom Treasure urge their surgical colleagues to think again about heart transplantation (p 509). “A privileged minority” receive transplants, they explain, and patient outcomes depend largely on the health of the donor heart. The future instead lies in angiotensin converting enzyme inhibitors and surgical alternatives, such as implantable ventricular assist devices.