NHS Confed oversimplifies polyclinic debate

James Gubb, 17 April 2008

The NHS Confederation today publishes a report looking at polyclinics, widely anticipated to be recommended as part of the conclusions of Lord Darzi’s Next Stage Review in the summer.
The Confed puts a pretty strong case for them, describing the principles behind them as ‘in line with the way that healthcare is developing across the world’ and listing the potential benefits: larger groupings of primary care professionals, economies of scale, a reduction in expensive hospital activity, better integration of services and space created for community health care. It thinks, with all this laid out, that the proposal has ‘generated a surprising level of opposition’. Really?

There’s no doubt that patients would benefit hugely from better integration between primary and secondary care and from stronger primary care per se. The historic division is based on a 1948 model of health care, not a 21st century one, and leads to massive problems in the coordination of care; the most poignant evidence of which is the high, and rising, level of hospital readmissions and admissions to hospital for conditions best managed in primary care. A compelling case, it may seem, for the reconfiguration of services; for example more diagnostics and outpatient appointments in an out-of-hospital setting….which sounds like the road to polyclinics. But is it?
Not everyone is as convinced as the NHS Confed. Professor Martin Roland, a medical expert, is one such person. Clearer and more effective patient pathways are certainly needed, but writing in the BMJ he cites a discerning lack of evidence from NHS closer-to-home pilot sights that new services in the community are economically justifiable when used as a substitute for existing hospital-based services. Specialists are likely to be less efficient when deployed out of hospitals; patients in small practices actually rate their care more highly on access and continuity; and small practices achieve, on average, a higher quality of care based on QOF points.
All is not as simple as it would seem. And a further point. Opposition is ‘surprisingly strong’ also because the medical profession, quite reasonably given the constant bashing they have taken from central directive after central directive, doesn’t believe the government have the answers. And they are right. The polyclinic has become the ‘next big idea’; the next big ‘solution’ to the NHS’s woes; the panacea the government is clinging to, to try to convince an ever more sceptical electorate they have a health policy in their head.
The sad fact is that, as happens all too often, the conclusion has been made before any engagement or evidence-base has been tested. The Darzi Review will trawl out recommendations for polyclinics, SHAs will push them and PCTs will be obliged to commission them. GPs will be increasingly alienated, have little if any buy-in and it’s the patient that will be on the receiving end.
Some will say this is overly cynical, but let’s have a quick look at London SHA, where polyclinics were recommended by Lord Darzi in his report ‘Healthcare for London: A framework for Action’ last year. Consultation supposedly happened, yet many PCTs had already earmarked buildings and pressed ahead with service cuts and reconfiguration plans before the outcomes of the discussions on the proposals were even known. Not a constructive framework for a responsive, patient-centred service.
The government should be looking at alternatives. I wouldn’t mind betting that the root cause of over half of NHS staff reporting to the Healthcare Commission that they didn’t think patient care was a priority where they worked is constantly shifting government priorities, targets and micromanagement. More of the same – in whatever guise – will not do.
Instead of polyclinics, Prof Roland calls for incentivising continuity of care; reducing financial incentives for hospitals to admit patients as emergencies; and developing new approaches to commissioning care – such as involving hospital specialists in joint commissioning with GPs – to integrate care for those with chronic conditions and complex co-morbidities.
This sounds sensible; and there are tools in the box to follow it through. Practice-based commissioning is one option. And why, for example, is the government not considering the quite frankly very sensible proposals made by the Royal College of General Practitioners in its roadmap document published earlier this year that, incidentally, has the support of its members, the BMA and NHS Alliance? Instead of the central imposition of polyclinics, it calls for a federated model; with GPs leading the strategic and organisational development of collaborative groupings or federations, that would work together to expand and integrate primary health teams – including diagnostics and mental health – and organise efficient pathways to acute care.
Through such a mechanism we could envisage, in the long-run, choice for patients between such federations, with individual capitation budgets following them, and all the benefits of a much closer link between the individual patient and health professionals – a policy also being flirted with in Sweden.
It’s interesting that one of the most effective health systems in the world, Kaiser Permanente in California, lives and breathes such a model and has at the core of its culture a recognition that its well-being comes from the well-being of its members/patients.