Darzi centres: an expensive luxury the UK can no longer afford?BMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c6287 (Published 08 November 2010) Cite this as: BMJ 2010;341:c6287
Do general practitioner (GP) led health centres have a future? Conceived as part of the then health minister Lord Darzi’s Next Stage Review of the National Health Service, and popularly referred to as “Darzi centres,” the Labour government ordered 150—one for every primary care trust (PCT). They would be open 12 hours a day, every day of the year, offering walk-in services and having their own lists of registered patients. London was to take them a step further with polyclinics offering diagnostic and other services traditionally provided in hospitals.
The Department of Health invested the lion’s share of its £250m (€285m; $403m) “equitable access” fund in GP led health centres, and the first opened in November 2008. All but about a dozen PCTs had commissioned one by the time of the general election,1 and seven polyclinics had opened in London.
Now, however, Darzi centres find themselves stranded in a very different political and economic climate. Incoming health secretary Andrew Lansley was quick to axe London’s polyclinic programme, declaring that “a top-down, one-size-fits-all approach will be replaced with the devolution of responsibility to clinicians and the public.”2
Then NHS Stockport announced the first closure of a GP led health centre. It will not be the last.
An expensive luxury
“In the majority of cases they are likely to disappear,” says Richard Vautrey, deputy chair of the BMA’s GP committee. “The vast majority were imposed on PCTs where they were not required. Some will continue where they’ve been put in the right place and are fulfilling a genuine need. But many will be seen as an expensive luxury.”
Warnings that the policy could unravel began early. The Commons health committee bemoaned the lack of pilots: “Evidence that similar centres in Germany and the US improve the quality of patient care and provide value for money is mixed.”3 Despite Lord Darzi’s intention that the centres should “reflect local need and circumstance,”4 many GPs perceived them not as adding value but as representing a rival service—often run by the private sector.
“The policy line appeared to be, ‘this is going to make you get on your mettle and stay open 24 hours a day,’” says Iona Heath, president of the Royal College of General Practitioners. “That’s alienating and infuriating when you think you’re working your socks off just to respond to the people coming through the door.”
NHS Stockport confirms it felt its centre was unnecessary and opened it under pressure. Practices are evenly distributed throughout the area, and it already provided a service for homeless people. The centre resulted in “costly duplication” by attracting three times as many patients as expected to its walk-in service, 99% of them already registered with a Stockport GP, a spokesperson says. Yet accident and emergency attendances at Stepping Hill Hospital simultaneously rose by 5%. Forced to save £20m, the PCT closed the centre’s walk-in clinic in September, saving £800 000, though an out of hours service will continue. It reports “absolutely nothing” by way of protest from the public.
That will not be the experience everywhere. In fact NHS Peterborough looked set to beat Stockport to announcing the first closure until patient power brought a change of heart. Faced with deteriorating finances, the PCT had asserted that “current urgent care services cannot be sustained in their present form,” and began consultation to close its Alma Road primary care centre. Registered patients were fewer than expected and could be transferred to the 11 other practices within a mile, and the PCT already provided another walk-in clinic.
But according to Rupert Bankart, medical director of 3Well Medical, which runs Alma Road, “vehement” opposition from patients and councillors on the local authority’s health scrutiny commission forced a rethink. “We provide an excellent service and patients love it. No one else is prepared to work seven days a week from early morning to late at night. This is what we need in this deprived area. We’re very much part of the community and have engaged with it from the beginning.”
Though registrations were slow to start, Dr Bankart admits, the centre is now projected to meet its target of 2000 patients by the end of 2010, while its 30 000 walk-in patients a year exceed target. The local emergency department has noted no fall in attendances other than for children, but Dr Bankart says the centre’s patient survey found two thirds would otherwise have gone to the emergency department. He denies the centre has had any adverse effect on neighbouring practices, with one nearby planning to extend its premises.
NHS Peterborough has now stopped consultation on Alma Road’s future. “This isn’t about making savings but about making services more efficient and easy for people to access and navigate,” says chief executive Paul Zollinger-Read. “We will now start to review all of our urgent care services and how we can make the whole system more accessible.”
But the reprieve has come at a price: the PCT insists the centre reduces its costs. “We have very challenging costs already,” says Dr Bankart. “But we’re here to serve patients not to make money, so we wanted to carry on.” He insists GP led health centres can provide value once the investment costs of their early years are behind them. They are “part of the solution, not the problem.” 3Well Medical is keen to be involved in GP commissioning and is talking to “various players” already. “Gradually we’re being accepted.”
GP commissioners will be key to the centres’ long term future. Martin Roland, professor of health services research at Cambridge University and a GP, believes that where centres occupy new buildings suitable for providing a range of services in the community, commissioners will be interested in them, particularly where the surrounding NHS estate is in poor condition. “It partly depends on whether extended hours are something that GP commissioners will be required to provide, but they may well be.”
Even then, however, commissioners could turn instead to out of hours services—almost all of which now have their own premises. “They might end up as the same thing,” says Professor Roland. Ultimately it will be up to each GP led health centre to prove it is serving genuine need cost effectively, in which case it would have good grounds to survive, he argues. “The risk in the interim is that the need to save money may mean they have to close even where there is a need.”
Closing centres before their five year contracts expire was discussed with Mr Lansley at the Royal College of General Practitioners’ annual conference. He told doctors who were disgruntled that GP consortiums could be saddled with costly and superfluous centres: “I wasn’t an advocate for the imposition of Darzi centres. But I have to tell you that a contract is a contract.” He added: “For the continuing life of that contract you will have the responsibility to use that contractual relationship to get the best value you can out of that facility and service. Beyond the life of that contract you will be able to make new decisions.”5
Some believe the situation is less clear cut. NHS Peterborough invoked the “no cause” clause standard in alternative provider medical services contracts, which is seen as enabling PCTs to cancel a deal at will. One GP, who contemplated bidding for Darzi centre contracts but decided against, says: “These contracts leave GPs more vulnerable than they realise. There was no negotiation on the contract terms. We were invited to tender, not negotiate. The contracts were very well written in favour of the PCTs. A PCT completely determined could probably do something to close a centre. Public pressure and demonstrating need might be the most important weapons for GPs and companies who want to maintain their contracts.”
Keeping patients out of hospital
If large numbers of GP led health centres closed, the NHS would still be left with the imperative to shift more care out of hospitals. “We haven’t created organisations of scale in the community to stop people going into hospital for scheduled and unscheduled care,” says Mark Hunt, a GP and managing director of healthcare for Care UK, which runs 12 GP led health centres throughout England.
He argues that compared with other developed countries, the UK has overinvested in hospitals and that 40% of accident and emergency patients could be treated in Darzi centres. The impetus needs to be towards facilities like GP led health centres, perhaps exploiting the spare capacity that often exists in premises built under the local improvement finance trust (LIFT) scheme to move beyond providing urgent care and adding services such as diagnostics.
“My sense is the picture is going to evolve. Our centres have five years to run, and it’s early to say what will happen,” says Dr Hunt. “Some of the 12 have definitely done less well than others, but our response has been to work with the PCTs to adapt the services to see what would be the best result for patients.”
Perhaps a glimpse of the future is afforded by the very first centre to open, two years ago this month. Bradford’s Hillside Bridge Health Care Centre and two others in West Yorkshire are run by social enterprise Local Care Direct, whose clinical director, Georgina Haslam, reports spectacular success in fulfilling its contract to improve access in areas of inequality. But therein lies a problem: numbers of walk-in patients have far exceeded expectations without reducing attendances at accident and emergency.
“The threshold for patients to access an appointment through the walk-in service has become too low. In particular, patients with short term symptoms have attended. There’s been no encouragement to self care,” says Dr Haslam. Often patients turn up for a second opinion having already consulted their GP, so have little incentive to register with the centre. “They’ve also then gone to accident and emergency if they haven’t liked what happened at the walk-in.”
Local Care Direct is now working with the PCT to change the model. Face to face contact with a GP would be more carefully managed, patients first seeking advice by telephone. “We’re not there yet, but maybe in nine months. . .”
A revised contract would emphasise better outcomes and health promotion, more in line with the quality and innovation agenda, says Dr Haslam. “The future is about being flexible and trying out different models, particularly in inner cities. We don’t know how patients will respond. It will require a leap of faith.”
Cite this as: BMJ 2010;341:c6287
Competing interests: The author has completed the unified competing interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declares no support from any organisation for the submitted work; no financial relationships with any organisation that might have an interest in the submitted work in the previous three years; and no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Commissioned; not externally peer reviewed.