Polyclinics in England

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Polyclinics in England were intended to offer a greater range of services than were offered by current general practitioner (GP) practices and local health centres. In addition to traditional GP services they would offer extended urgent care, healthy living services, community mental health services and social care, whilst being more accessible and less medicalised than hospitals. [1] A variety of models were proposed, [2] [3] ranging from networks of existing clinics to larger premises with several colocated general practitioner (GP) practices, more extensive facilities and additional services provided by allied healthcare professionals.

Contents

The incoming health secretary in May 2010 Andrew Lansley put on hold all plans to increase numbers of polyclinics and to relocate GPs to them pending a review of policy under the new coalition government, [4] after a review by management consultants McKinsey revealed "NHS managers had vastly overestimated the ability of polysystems to handle the shift in care from hospitals and revolutionise GP care".

Operational polyclinics

On Wednesday 29 April 2009, the first seven polyclinics in England opened in London, marked by the opening of the Loxford Polyclininc by Lord Darzi. The seven were: [5] [6]

Polyclinic services

The polyclinic model proposed in London will provide:

The government accepts that the polyclinic model may not be suitable for rural areas but may be popular in the larger conurbations.

History

Health centres offering a mix of community-based health care services have existed in England since the early years of the National Health Service (NHS). They have typically provided specialist care such as ophthalmology, podiatry, dentistry, minor injuries nursing, and therefore provided services that fell between that of the GP service and those available at the hospital.

Some primary care trusts in England attempted to bring together even more services into such centres, most notably by co-locating GPs, health laboratories, pharmacies and other services under one roof. The Heart of Hounslow Centre for Health for example has GP services, outpatient care, physiotherapy, dentistry, podiatry, social care outreach, mental health services for children and a gym to help in rehabilitation. All these services take place in a purpose-built facility. [15] However, the centre does not provide urgent care and only has a limited range of diagnostics.

Polyclinics were proposed only for London by Professor the Lord Darzi of Denham in his review of healthcare in London for NHS London: Healthcare for London: A Framework for Action. [1] In the final report of his subsequent national review for the Department of Health, High Quality Care for All [16] Lord Darzi has not suggested that polyclinics would be appropriate elsewhere; instead he suggests "GP-led health centres". He explained the difference between the two models to the House of Commons Health Select Committee on 19 July 2008. [17]

A key principle of A Framework for Action is to "localise where possible, centralise where necessary." This would move "routine healthcare" away from acute hospitals and into community-based centres to provide a one-stop-shop for health care. "More complex care" would remain centralised. A key part of the plan is to extend the opening times of such centres, especially in the evenings, to make them more accessible to working people.

While polyclinics had not been widely implemented across England prior to 2008, they have existed in Australia, France, Germany (since 2004), Northern Ireland, Switzerland and Russia; [18] and in many countries across Asia and Africa, although several of these countries are now seeking to remove them. [19] In Russia, where they were introduced under communism, attempts were made to replace them with a more western model by the new Russian government. However, the Russian polyclinic model proved robust and the authorities' prescriptive interference failed. [20]

Rationale

The Department of Health and the government claimed that polyclinics offer:

  1. A way of providing more services in the community closer to home and at more convenient times (including antenatal and postnatal care, healthy living information, community mental health services, community care, and social care and specialist advice)
  2. An improved structure within which GPs and other health and social care professionals can work together
  3. Improved care for patients with chronic or complex conditions
  4. A shift in the focus of urgent care out of hospitals and into polyclinics. [18]

A report by the King's Fund has questioned many of these, observing that:

  1. Access to services was likely to be harder in rural areas and in urban areas where new buildings were not situated close to transport hubs
  2. Simply putting healthcare professionals in the same location is in practice often not sufficient to generate co-working or integration of care
  3. While the co-location of multiple services presents opportunities for delivering more integrated care, particularly for people with chronic diseases, the evidence suggests that in practice these opportunities are often lost, and accessibility of primary care is likely to be reduced for most patients if their GPs move into polyclinics, particularly in rural settings (a point emphasised in The Times [21] )
  4. There is limited evidence that quality of care for services shifted out of hospitals is comparable, and there is evidence that quality may be decreased in certain cases; the limited inspection and accreditation of out-of-hospital care is also a serious deficit in quality assurance

The report also observed that the proposals were likely to increase professional isolation, and threaten both professional development and motivation, and continuity of care, and that pre-existing problems in healthcare to do with the lack of an overall governance structure, and unclear lines of accountability had not been addressed.

It concluded that while polyclinics offered real opportunities for some health communities to establish more integrated, patient-focused care, these would only be realised with considerable investment of time, effort and resources into their planning and development, and that the primary focus should be on developing new pathways, technologies and ways of working rather than new buildings. [22]

The Conservative Party leader David Cameron did not object in principle to the case for polyclinics but is worried that they might be imposed against the wishes of communities. He suggested that close to 1,600 GP surgeries may have to close across the country as a whole if polyclinics were established in the way the government is suggesting. [23] The Health Minister Ben Bradshaw, however, denied that individual GP practices would be closed as patients would remain registered with their existing GPs. [24] These figures have also been dismissed [25] by Dr Laurence Buckman, chair of the British Medical Association's General Practitioners Committee.

Funding

It was unclear whether polyclinics would be funded in addition to existing GP services or whether they will take funding away from existing practices. Although Lord Darzi claimed that their funding would be in addition to existing funding, [26] following the publication of his report, eight London primary care trusts drew up plans to relocate more than 100 urban GP surgeries into polyclinics. [27] The Conservative Party claimed that unless existing surgeries close, polyclinics will leave a £1.4 billion "black hole" in public finances. [28]

Implementation

Polyclinics were originally planned for and implemented in London, with every primary care trust in the country subsequently required to have at least one new "GP-led health centre". [24] [29] [30] All of the first wave of polyclinics in London, which formed a pilot of the model, were of the federated/networked model and involved "existing services working more closely together". [31]

As of August 2008, more than a quarter of PCTs had plans to implement a polyclinic or GP-led health centre, [32] including Birmingham, Cumbria, Lincolnshire, Rochdale, Cheshire, Essex and Bolton. More than 50 PCTs admitted that they would not consult local communities over plans to build polyclinics, some citing advice from the Department of Health as the reason, despite repeated government promises that they would not be introduced without consultation. [33]

The country-wide rollout of GP-led health centres was criticised by doctors' leaders and patient groups. Dr. Richard Vautrey, deputy chairman of the BMA, called it "a government plan that is potentially going to waste hundreds of millions of pounds of scarce NHS resources, creating very large health centres that many areas of the country simply don't need or want", [34] while the Patients Association noted that gathering services under one roof in rural areas "may actually put patients at risk" and noted that rural patients already had to travel further and were more reliant on primary care. [35] The other political parties have also criticised it, with the leader of the Liberal Democrats Nick Clegg calling it "the central imposition of a polyclinic on every primary care trust, regardless of the geography, demographics and clinical needs of the area" while acknowledging that they might be a good thing for people in some communities [36] and Conservative leader David Cameron suggesting large-scale closures of existing GP surgeries. [23]

The results of a freedom of information request by Pulse on the plans for polyclinics show that nursing staff could outnumber doctors by up to three to one. The BMA said the plans would lead to "cut-price general practice". A spokesperson for the Department of Health said "where people choose to register with a GP-led health centre, they should expect the same quality and continuity of care from GPs and other primary care clinicians as they would from any other GP practice". [37] [38]

On 10 September 2008, an NHS London press release [39] and fact sheet [40] announced details of 5 of a possible 13 polyclinics in the first wave in London. [41] They were to be developed by the following primary care trusts:

Also anticipated in the first wave were: [41]

Opinion

Opinion on the plans for polyclinics was polarised.

Polyclinics are based on long term trends of what works best in healthcare, and in fact there are many practices successfully operating under a similar model already. As such we have been genuinely surprised to see the level of concern surrounding these proposals among the health community and patient groups. What we need now is a calm and balanced debate about how to bring out the best in our primary care services. The name may pose a problem. Polyclinics may be associated with the previous soviet system of healthcare, however what is proposed here has no real connection to this at all. While it may sound like the polyclinic system will not resemble the service currently provided by family doctors, in reality it should build on what is best in general practice. Of course this is not something that will work in every circumstance, but delivering better organised care focused on the patient is surely a good thing. This is why it is crucial that politicians and health professionals fully engage with the benefits that polyclinics can bring. Knee jerk reactions focussing on possible problems based on pre-existing agendas rather than potential solutions could seriously jeopardise progress for patients.

With HIV now a long-term condition, polyclinics have a very important role in the delivery of HIV care. Many routine services, such as regular blood tests and check ups shouldn't require a trip to a hospital-based clinic. Integrating services can only make life easier for people living with HIV so it's definitely a welcome move. [39]

We welcome the intention of providing an integrated local health centre delivering a wide range of services in a joined-up approach. If this is done with care it could benefit many older people. While older people may be worried about possible changes to the services they currently use, many suffer at present from lack of coordination between different health and social care services. The NHS needs to work with and listen to local people's views about the services to be provided. We need improved, responsive services and easy access for Londoners of all ages from all communities. [39]

Polyclinics were a centrepiece of the Soviet model of healthcare delivery, but many countries of Central and Eastern Europe have abandoned them over the past two decades in favour of a system of general practice that draws extensively on the British model. Advisers from the World Bank, the EU, and many bilateral donors agreed that the polyclinic had failed to deliver modern, integrated health care and saw general practices as the future. [47]

External references

Related Research Articles

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Family medicine is a medical specialty within primary care that provides continuing and comprehensive health care for the individual and family across all ages, genders, diseases, and parts of the body. The specialist, who is usually a primary care physician, is named a family physician. It is often referred to as general practice and a practitioner as a general practitioner. Historically, their role was once performed by any doctor with qualifications from a medical school and who works in the community. However, since the 1950s, family medicine / general practice has become a specialty in its own right, with specific training requirements tailored to each country. The names of the specialty emphasize its holistic nature and/or its roots in the family. It is based on knowledge of the patient in the context of the family and the community, centering on disease prevention and health promotion. According to the World Organization of Family Doctors (WONCA), the aim of family medicine is "promoting personal, comprehensive and continuing care for the individual in the context of the family and the community". The issues of values underlying this practice are usually known as primary care ethics.

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Ara Darzi, Baron Darzi of Denham

Ara Warkes Darzi, Baron Darzi of Denham, is an Armenian-British surgeon, academic, and politician.

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