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29 August 2008
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The polyclinic debate has been raging for months and is clouded by controversy, emotion and misconceptions.
Proponents of polyclinics see them as a means to integrate services, reduce hospital visits and improve choice with “one-stop shop” health and social services.
Those against say that polyclinics have a questionable evidence base and threaten to destabilise primary care, commercialise general practice and destroy the personalised GP care loved by patients.
Polyclinics have become synonymous with one man – surgeon and health minister Lord Ara Darzi, who last summer proposed establishing a network of polyclinics in London as a way of addressing specific problems with aging GP services in inadequate buildings.(1)
These polyclinics will open for extended hours, provide diagnostic facilities and a range of other services such as mental health, family planning and sexual health and smoking cessation clinics, along with social care, debt and housing advice.
Muddying the waters
But when, last October, Lord Darzi outlined plans for 150 new GP-run health centres and 100 new GP practices – to be open 8am to 8pm seven days a week – as part of his national NHS Next Stage Review, critics claimed that these too were essentially polyclinics.(2)
Dubbed “Darzi centres” and “Darzi practices”, these new facilities are intended to offer walk-in-services and a range of other primary care services that can be accessed by anyone – whether or not they are registered there. All primary care trusts (PCTs) have been told to open one in their area.
The debate became inflamed when both the Conservatives and the British Medical Association (BMA) claimed the new centres would put some GP practices out of business. Tory leader David Cameron said as many as 1,700 practices could close, and the BMA sought the support of patients through a high profile “Support Your Surgery” campaign.
Dr Laurence Buckman, chairman of the BMA’s GPs Committee (GPC), says: “Whether called ‘polyclinics’, as in London, or ‘health centres’, these developments have the potential to undermine long-established routes for delivering quality patient care.
“Communications from central government to strategic health authorities make it clear that the contracts for these polyclinics/health centres are likely to be APMS (Alternative Providers of Medical Services) contracts, which is the route under which private commercial companies would provide general practice care.
“This commercialisation of patient care in the community is the very opposite of the personalised care the government espouses and which family doctors already provide.”
Health ministers insist the new health centres and practices and the London polyclinic model are separate developments. They have also stated publicly on several occasions that they have no agenda to close practices.
Dr James Kingsland, a GP in Wallasey, Chairman of the National Association of Primary Care and an adviser on the NHS Next Stage Review primary care strategy board, says: “Somebody set the hare running on polyclinics, and now there are so many urban myths flying around that the whole concept has got completely lost in translation.”
The exciting idea behind the polyclinic model, he says, is the development of integrated care organisations. But although the primary care strategy talks about improving health outcomes by developing integrated collaborations across primary, community and secondary care, polyclinics per se are not a key feature and were never intended to be.(3)
Dr Michael Dixon, NHS Alliance chairman, agrees: “I know that many GPs and others have difficulty with the word ‘polyclinic’, with its impersonal and biomedical connotations. But the concept of bringing practices together and providing a greater range of integrated services in the community has to be right.
“It might be true that small is beautiful, but professional isolation and poorly integrated services are not.”
The polyclinic concept is not new. The NHS Alliance and the Small Practices Association put forward a “nested practice” idea in 2005. This model envisages GP practices on several sites collaborating together and with other local services to provide a “virtual polyclinic”, or a number of small practices located at a single new site, perhaps with shared management services.
The Royal College of General Practitioners (RCGP) has also for some time been developing the concept of “Primary Care Federations”, with practices working to share resources, expertise and services, and published its conclusions in its Roadmap vision in September 2007.(4)
However, at a recent debate on polyclinics, hosted by the thinktank Civitas, RCGP Chairman Professor Steve Field said that when a panel of 60 patients convened to look at the Darzi proposals for London, the overwhelming majority were not sold on the idea.
“Even if polyclinics work for the young and able-bodied and upwardly mobile – like many of the advisers to the government – they certainly would not suit the elderly, the vulnerable and those with long-term conditions because patients will have to travel further to access care,” he commented.
He said that, rather than herd GP practices into big buildings, it would be preferable to build on the quality care already established in smaller practices who could work together in a federated way.
“Polyclinics, or large Darzi centres or GP-led health centres, are being imposed on all PCTs in the country, and even areas that have high-quality academic practices and high-quality nonacademic practices are feeling threatened. So why have we got a system where a lot of money is going into building infrastructure and new centres but also managing to alienate all the professionals at the same time?” he asked.
Costs and resources
Professor Martin Roland, a GP and Director of the National Primary Care Research and Development Centre (NPCRDC) in Manchester, said: “I am surprised there has been remarkably little discussion by politicians about the cost of it all. In this review it’s as if we could have everything we wanted – and we can’t.”
Part of the debate was about moving specialist care out into the community. But, Professor Roland said, research has shown that specialists may be less efficient when they work outside hospitals. This policy was also producing a new type of specialist, the GP with a special interest (GPwSI). NPCRDC’s research had shown there was significant concern about the quality of care provided by some GPwSIs, whose salaries were also expensive.
“There is not enough discussion at the moment on how we can use these new developments to provide care not only more effectively but also more cost-effectively. There is a risk of an expensive excursion into new buildings without a very clear thought as to what they are to do,” he said.
But Professor Stephen Smith, Chief Executive of Imperial College Healthcare NHS Trust and Principal of the Faculty of Medicine at Imperial College, said the UK had some of the poorest outcomes for diseases such as stroke, cancer and cardiovascular disease.
This could be because the primary care system was so disintegrated from the secondary care system, he suggested.
“We need to provide a mechanism for integrated care – it’s an absolute buzz word at the moment; you can’t go to any policy discussion in medicine without the idea of integrated healthcare. How many visits to health services does it take to have a gall bladder removed, for example? Patients feel like shuttlecocks – there is little or no integration of care,” Professor Smith said.
He warned: “If we continue to work in our silos, it will be inevitable that the patient will lose out and that will have direct consequences on results. We have to start changing the system. If we are going to achieve integrated care we need to create new organisations and new structures that can better meet the needs of patients.
“At the end of the day the bottom line is that health outcomes and patient satisfaction are the only things that matter,” he said.
1. Darzi A. Healthcare for London: A Framework for Action. London: Healthcare for London; 2007. Available from: http://www.healthcareforlondon.nhs.uk/pdf/aFrameworkForAction.pdf
2. Department of Health. Our NHS Our Future: NHS Next Stage Review – interim report. London: DH; 2007. Available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publicati…
3. Department of Health. NHS Next Stage Review: Our vision for primary and community care. London: DH; 2008. Available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publicati…
4. Baker M, Field S, Lakhani M. The future direction of general practice: a roadmap. London: Royal College of General Practitioners; 2007. Available from: http://www.rcgp.org.uk/pdf/Roadmap_embargoed%2011am%2013%20Sept.pdf