Will polyclinics deliver real benefits for patients? Yes
BMJ 2008; 336 doi: https://doi.org/10.1136/bmj.39577.488507.AD (Published 22 May 2008) Cite this as: BMJ 2008;336:1164
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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
Competing interests: No competing interests
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
Competing interests: No competing interests
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....
(accessed 18 May 2008)
Competing interests:
None declared
Competing interests: No competing interests
Benefits of Polyclinics.
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
Competing interests: No competing interests