Polyclinics: a force for integration or disintegration?

James Gubb, 9 June 2008

Lord Darzi’s Healthcare for London report, published last July, outlined ambitious proposals to introduce a series of polyclinics in the capital. While the national Next Stage Review currently being conducted may not take the London report as a template, it is likely that polyclinics are to form a part of Lord Darzi’s conclusions once again.
But what is there likely impact? Are polyclinics the emperor’s clothes – it’s certainly a new, untried, model – or could they serve as a means to the integrated care we all crave? At a debate hosted by Civitas last week, the medical profession and leading academics had their say.

A disintegrating force?
‘Polyclinics’, surmised Professor Steve Field, ‘risk a “Martini” style of health care: any time, any place, any doctor’.
He cautioned that before we start talking about new models of delivering primary care, we must properly understand the role of the GP: ‘open-ended, inclusive, holistic, personal, continuing and rejecting the inhuman’.
Patients he said – citing research by the Patient’s Association – above all value a regular relationship with their GP, which impersonal care in polyclinics could threaten. ‘Even if polyclinics work for the young and upwardly mobile’, he said, ‘they certainly won’t suit the elderly, the vulnerable and those with long-term conditions’.
Professor Martin Roland looked at three possible models of polyclinic: merging GP practices into a single building, putting community-based services into them and moving specialist care there. He highlighted the risks involved:
• Moving disparate small practices into central locations will involve greater travel time and less choice for patients.
• Patients like small practices and they actually do better in quality terms than larger ones.
• Costs may be exorbitant if care is duplicated. Professor Steve Field highlighted that general practice is both the most cost-effective part of the NHS and carries the highest levels of patient satisfaction.
• Moving consultants out of hospitals is inefficient if all they do not adopt new ways of working.
‘The polyclinic model taken alone’, Professor Roland said, ‘has the potential to fragment care if the driver for Chief Execs is if you don’t stick one of these things here you’ll lose your job’.
An integrating force?
‘In terms of patient outcomes’, Professor Steve Smith started out, ‘the UK is far and away from the best health care system. In fact, we have some of the worst outcomes for stroke, cancer and cardiovascular disease; and are right at the very bottom in terms of preventable deaths before the age of 75.’
He posited that the roots might in fact be our system that disintegrates primary care so strongly from secondary and tertiary care. In challenging the audience that ‘the status quo is simply unacceptable’, he stated, ‘it just doesn’t facilitate the closeness between the fancy and less fancy medical care’.
Indeed, there was widespread consensus that integration of care is extremely poor. Dr Oliver Bernath highlighted what he called an ‘inconceivable way of working’ that after six months in the NHS – after transferring from Kaiser Permenente in the US – he had not met a single primary care colleague, nor been able to be on the end of the phone for them.
Professor Field agreed that the quality of care – even taking just primary care – ‘is patchy and needs to be improved’. Professor Roland added that in some areas the primary care estate ‘is seriously deficient’, whereupon a polyclinic might be appropriate.
Returning to the cause of integrated care, Professor Smith argued that ‘polyclinics might just be able to bridge some of the gap [between primary and secondary care]’, citing the example of a very successful diabetic ‘polyclinic’ in Abu Dhabi run by Imperial that incorporates generalists, specialists, diabetologists, dieticians, cardiologists and renal medicine.
Unlike the NHS, where patients too often feel like ‘shuttlecocks in the system’, services are ‘brought together for the patient’.
An operational model, not to be centrally imposed
All the panellists were against central imposition. Dr Bernath argued persuasively that whatever happens around polyclinics, they must be an operational model to deliver integrated care ‘with or without a building around it where required’, not a centrally imposed directive.
The question, he put, ‘has to be what organisational delivery do we want to change and, following on from this, what facilities do we need’.
There was reasonable agreement that that the hub-and-spoke model put forward by Professor Field, with GP practices working together in federations encompassing larger centres and leading change was an attractive one.
‘We must start looking very carefully about the function of things that go on in buildings and we must, must, start looking at the system as a whole’, said Professor Roland.
For Dr Bernath, this would involve a switch from thinking about cost to thinking about value – with providers holding patient-specific data on this – and practice-based commissioners holding hard budgets for entire patient pathways.
But in his commentary, Sir Ian Kennedy cautioned all must be done in concert with patients.
Professor Smith acknowledged: ‘if the patient’s interests are really at stake, very different and surprising patterns of care would emerge’. He argued that in embracing integrated care we should also recognise the importance of creative competition (in his view between systems, not primary and secondary care) and avoid a return to producer protectionism.
To read a full transcript of the debate please click here. Comments are very welcome.