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Demise of Soviet polyclinics - is there a lesson to be learnt?
- Dennis Ougrin (27 May 2008)
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Re: Demise of Soviet polyclinics - is there a lesson to be learnt?
- Arvind Dayal (28 May 2008)
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Necessary Change
- Alfred P J Lake (31 May 2008)
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Benefits of Polyclinics.
- GEORGE Y CALDWELL, Singapore 259858 (22 August 2008)
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Dennis Ougrin, Kraupl-Taylor research fellow Child and Adolescent Psychiatry, King's College London, De Crespigny Park, London, SE5 8AZ
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The existence of polyclinics in Soviet Union has been used as an argument against the proposals of Lord Darzi (1). Although it appears that Darzi's reforms do not necessarily mean creating polyclinics as separate buildings (2), the underlying principle of integrated service provision has significant similarities with the health care system created in the USSR. The author’s first hand knowledge of working in a post-Soviet polyclinic might add to the current debate by examining the pros and cons of this system. Polyclinics were a cornerstone of the Soviet health care system created by Nikolai Semashko. They remain in rudimentary operation in most post-Communist countries. Polyclinics employ district physicians (in theory equivalent to the British general practitioners) each serving a population of about 2,000, as well as consultants providing a range of secondary care services. The advantages of polyclinics include immediate access to specialists, patient choice (it is up to patients to decide which individual specialist to consult if there is a choice within a specialty) and creating an opportunity for a close co-operation and mutual learning between the primary and secondary care physicians. There are also significant disadvantages (3). Firstly, polyclinics create a two-tier system of secondary care with the polyclinic specialists concentrating mainly on the less complex procedures and running a risk of loosing the skills they do not use. Secondly, the primary care doctors (district physicians) tend to refer a significant proportion of patients to the polyclinic specialists, undermining the gate keeping function of primary care. Finally, patients may perceive primary care physicians as obstacles to achieving "proper" care, yet the polyclinic specialist may be regarded as second rate consultants. This creates significant demands on hospital-based consultants who frequently end up providing services to the patients usually managed in primary care in Britain. The impact of establishing a system of polyclinics in the USSR was significant yet hard to interpret due to secular trends. Firstly, several population-based healthcare outcomes in the USSR were either on the par or superior to the ones reported by many Western countries (4). Secondly, considerable progress achieved in the first years of the USSR’s existence was not sustained and corrupt, de-motivated and de-skilled polyclinic professionals became a sad reality. The demise of polyclinics coupled with poor development of primary care services resulted in a significant deterioration of public health indicators (5). It is ironic that whilst most post-Soviet countries are dismantling polyclinics in favour of primary care, Britain seems to be doing exactly the opposite. Irony aside, perhaps the most important lesson to be learnt from the Soviet experience is that revolutions in health care are best avoided and that gradual development with a close monitoring of outcomes is the preferred way forward. References: 1. Dixon M. Will polyclinics deliver real benefits for patients? Yes BMJ 2008; 336: 1164 2. Thomas P. The professor lord Darzi interview. Lond J Prim Care; Apr 2008. http://www.londonjournalofprimarycare.org.uk/articles/690449.pdf (accessed 26 May 2008) 3. Vlassov V and Reza A. Lond J Prim Care (in press) 4. Anderson B and Silver B. Infant Mortality in the Soviet Union: regional differences and measurement issues Development Review 1986; 12: 705–737 5. United Nations World Population Prospects 2006 revision. Available at http://www.un.org/esa/population/publications/wpp2006/WPP2006_Highlights_rev.pdf. (accessed 18 May 2008) Competing interests: None declared |
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Arvind Dayal, HEalth Training Consultant New Delhi, India
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The author's report regarding the shutting down of polyclinics in the former Soviet countries is not entirely correct. For instance in the Central Asian countries accelerated efforts are underway to revive them as part of the Family Medicine system. How well they will function remains to be seen. Competing interests: None declared |
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Alfred P J Lake, Consultant in Anaesthesia and Pain Medicine Glan Clwyd Hospital, LL18 5UJ
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Necessary change has been resisted for so long it is not surprising that there are objections to the current initiative, perhaps in some ways understandable with its imposition from the centre. The descriptor ‘missing link’ is very apposite and it’s not too late to make the join; the impetus should, however, have come from within the profession. The five aims as detailed in the opposition statement are good ones and, self-evidently, not well delivered under the present arrangements. How the change is organised will be the key to success and flexibility to take firmly into account and interpret local needs in the context of central standards and targets must be built in. Integration between general practice, community and secondary care services is the appropriate goal. The much valued independent practitioner status of general practice is both its great strength and great weakness; the strength now eroded by changes in working practice (some in association with the new contract) as both patients and staff colleagues tell me. Continuity of care is of paramount importance but correctly stating that individual practices cannot provide a full range of services is something of an opposition own goal. Single handed (often lock-up) practice in cities has always been something of a time bomb and now it’s gone off the profession should grasp the moment. The range of general practice care provision in terms of quality and standard is much greater than in secondary care which itself should be a driver for change. More than 30 years ago, when I was a trainee, what I viewed as beneficial changes were in process including group practice and hospital practitioners but, it seems, momentum was lost. The development of a seamless better connected service for patients can only be good and would be facilitated by bringing primary and secondary care closer together. General practitioners should be pleased at the potential offered for their patients in terms of an improved ability to access many elements of care much of which for most can be closer to their homes. A critical mass is required (which rules out the small practice) but the benefits of more and better services include an on-call from the one ‘practice’, ‘emergency’ surgeries, extended hours, GPwSIs in many specialties (together with visiting secondary care consultants), radiology, improved continuity and accessibility, extended hours; need I go on? We mustn’t get hung-up on the name but polyclinic doesn’t cut it. One size will definitely not fit all, many will function as community hospitals, others will be less grand. The local served community can, surely, in each case, decide the designation of their facility for themselves. Competing interests: None declared |
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GEORGE Y CALDWELL, GENERAL PRACTITIONER 31 Balmoral Park, #18-33,, Singapore 259858
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Lord Darzi's Polyclinics should have been instituted back in 1948. With modern equipment, Radiology, fast Laboratory results, ECGs, minor theatres for small surgery and available Physiotherapy close-by, then the General Practitioner himself would have been able to get on with a diagnosis and start treatment. But these were not allowed. If also nearby there had been a small Cottage Hospital then he may have admitted a patient and undertaken the care and treatment himself. Cottage Hospitals were largely closed. "Centralisation" of everything was the politic and socialist theme. The Patient was a mere "digit" and so was the doctor. Patients travelled uncomfortably long distances and had to be used to long waits for test results which in reality took minutes to process. An X-ray takes three minutes to develop, not a month. A Urine test likewise. The Central Machinery of a hospital would close down at the end of the day instead of operating 24 hours. Polyclinics and their facilities and consulting rooms should have been on offer and available to the doctors of a district, without any compulsion to use them. They are understandably unsuited to rural and sparsely populated areas. Now that doctors have a high salary for the little work they allow themselvs to do, it is understandable that they are reluctant to staff these new Polyclinics which will perhaps require more work to be done, for the same large salary. Why work? Better then by far to pay for each item of service rendered and do away with that inflated salary structure. More work for more pay! Happy bunnies all round! Competing interests: None declared |
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