BMJ  2008;336:1165 (24 May), doi:10.1136/bmj.a130

Head to Head

Will polyclinics deliver real benefits for patients? No

¹ Aylesbury Medical Centre, London SE17 2XE

Government proposalstoestablish polyclinics are intended to reshape NHS services. Michael Dixon (doi: 10.1136/bmj.39577.488507.AD) believes they will deliver more patient centred care, but Stewart Kay thinks they are an unnecessary change

Healthcare for London’s A Framework for Action offers radical solutions to the problems that the health minister Ara Darzi has identified.¹ Although only part of a very comprehensive review, the polyclinic has grabbed the headlines.

Three types of polyclinic are described in the consultation document Consulting the Capital, each serving a population of 50 000 patients.² The networked polyclinic is essentially the current model, where a group of practices, as part of a locality cluster or a practice based commissioning group, share referral protocols and care pathways into secondary care, and a wide range of community based enhanced services. Same site polyclinics bring together practices under one roof to share access to an extended range of services.

The third model, and most controversial, is the hospital polyclinic. The hospital polyclinic is the preferred model of NHS London (London’s strategic health authority). NHS London plans to have a polyclinic alongside each London accident and emergency department and similar units on other sites in direct competition with existing general practices. If no practices wish to relocate to these sites, a service heavily reliant on non-vocationally trained doctors and other clinicians has been suggested.

This redesign of primary care services is not needed, will not deliver benefits to patients, and is already having a negative impact on general practice.

Lord Darzi has failed to recognise, or ignored, the high quality of current general practice and the commitment and innovation of its clinicians. General practices in London have evolved and developed organically to provide a wide range of services to diverse communities, often subtly different within a small locality. All of Lord Darzi’s aims could be achieved by traditional general practice with appropriate support and adequate funding. Currently, development in general practice is blighted by lack of investment in premises; funds being reserved for Darzi new builds; reluctance of primary care trusts to unbundle contracts slowing access to diagnostics; and the snails’ pace of movement towards practice based commissioning.

Improvement without polyclinics

Traditional general practice provides the best model to deliver Lord Darzi’s five published aims:

Focus on individual need and choice—The smaller and more local traditional general practice, which has evolved with its community, can more easily serve the needs of old, young, and vulnerable people. Continuity of care and personal care are more difficult to provide in large units. In a recent survey by Londonwide LMCs of 1562 patients across 24 primary care trusts, only 1 in 10 patients favoured the polyclinic model over their current practice.³

Local where possible, centralise where necessary—Local means traditional general practice. When individual practices can’t provide a full range of services, cluster arrangements can. As 80-90% of medical encounters happen in general practice, this is the part of the service which needs to remain close to patients, not moved to an arbitrarily situated polyclinic. Hospital attendances are being reduced by new care pathways and increasing investigation and management in the community; moving outpatient clinics away from hospitals produces little benefit for patients. Same site clinics have existed for many years with varying degrees of success. Polyclinics on this model could be developed when clusters of practices find it difficult to develop within their current premises. Unfortunately, few sites of this size are available, and the usual solution for the NHS in London is to redevelop old hospital and community clinic sites, which are seldom as well situated for patients.

Joined-up care and partnership—General practitioners have a long history of working in multidisciplinary teams. Transfer of staff and resources to polyclinics would offer no improvement and would hamper further development in general practice.

Prevention and health education—Advice on healthy living and health education are best delivered in a relationship of trust between an individual clinician and a patient. Polyclinics would be no more effective.

Health inequalities and diversity—Patients who share a first language that is not English often live in close proximity, and a traditional practice can adapt to meet their language, cultural, and medical needs, whereas a multipractice clinic could not. In some communities a local practice is considered a safe place for families. The vulnerable are less likely to access a large and more distant clinic.

General practice already provides the suggested components of a polyclinic (community services, minor procedures, extended hours, health education) or they are easily accessible by patients elsewhere (urgent care centres, outpatients, diagnostics).

The case has not been made for polyclinics delivering real benefits for patients. The concept of the polyclinic resembles the illusion of the emperor’s new clothes, asking us to accept a model with no true substance. The polyclinic model is expensive, based on untested assumptions, and potentially harmful to existing practices. Except in very few circumstances, polyclinics will seem an unattractive option for practices and patients, but will provide an ideal opportunity for wider private sector involvement in the NHS; better value is provided by investing in the current model of general practice.

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Competing interests: SK is chair of the governance board of Londonwide LMCs and a member of the BMA’s General Practitioners Committee.

References

1. Healthcare for London. A framework for action.2007. www.healthcareforlondon.nhs.uk/pdf/aFrameworkForAction.pdf
2. Healthcare for London. Consulting the capital.2007. www.healthcareforlondon.nhs.uk/pdf/consultingTheCapital.pdf.
3. Londonwide LMCs. Patient survey May 2008. www.lmc.org.uk/news/news-detail.aspx?dsid=1961.

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