Feature Integrated Care

Are Darzi-style clinics set to make a comeback?

BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f343 (Published 21 January 2013) Cite this as: BMJ 2013;346:f343
  1. Gareth Iacobucci, news reporter
  1. 1 BMJ, London WC1H 9 JR, UK
  1. giacobucci{at}bmj.com

They were white elephants of the noughties, but Gareth Iacobucci reports how a new incarnation of the polyclinic could help GPs deliver the NHS reform agenda

In 2008, polyclinic was a buzzword in the NHS. The concept of large modern buildings housing general practitioners alongside specialist services gained traction when surgeon turned Labour health minister Ara Darzi identified them as a key mechanism for reshaping primary care in his report on new ways to deliver healthcare in London.1

The proposals brought vocal opposition from the BMA, which campaigned against polyclinics 2 amid fears they could threaten traditional general practice by encouraging private sector providers to run new centres. But Darzi’s vision was soon extended to the whole of England when his NHS Next Stage Review3 ordered 150 new polyclinics, which soon became known as “Darzi centres.”

Designed to improve access to primary care while reducing reliance on hospitals, the centres were envisaged as “one-stop shops” for both registered and walk-in patients.

But polyclinics proved costly white elephants, with many closed in subsequent years after failing to deliver value for money.4 In some cases, the number of walk-in patients far exceeded expectations without reducing pressure elsewhere in the system, and the coalition government subsequently asked primary care trusts to consider decommissioning contracts.5

The term polyclinic was quickly abandoned in NHS circles after this unsuccessful venture. But although the term is dead, new developments suggest the concept is re-emerging.

Reincarnation

The Frome Medical Centre, a new £10.5m (€12.9m; $16.9m) health complex in Somerset, opened this month to much local fanfare, with the promise of providing easily accessible primary and secondary care to more than 30 000 patients.

The project was conceived in 2001, some seven or eight years before Darzi’s plan, but has only now come to fruition after five general practitioner partners dug into their pockets and invested £100 000 each and gained planning permission.

On the surface, this purpose built structure bears all the hallmarks of a polyclinic. Patients can access 130 health professionals, including more than 30 GPs, and hospital consultants provide a range of outpatient services, such as minor surgery and mental healthcare clinics.

Within these brightly coloured walls—its interior looks like an Ikea showroom—a host of private services rent space from the GPs, including a pharmacy, opticians, chiropractor, and even a healthy eating café for patients and staff.

Careful attention has been paid to the design and feel of the 4000 m2 building; roving receptionists “meet and greet” visitors, doctors still collect patients in person rather than through an intercom, and distinct “pods” house smaller groups of GPs to retain the feel of a small practice.

But although it may appear like Darzi’s vision incarnate, Mark Vose, GP partner at the Frome Medical Centre, cites some subtle but important distinctions.

“Polyclinics were really primary care based,” he suggests. “What’s different about this is our vision to bring secondary care here. Let’s take gynaecology. It is a very operation based specialty, yet now you’re seeing gynaecologists brought in as community gynaecologists because they realise you can do so much—for example, biopsies and hysteroscopy—in the community.”

In this regard, the building has more in common with Darzi’s original London polyclinics than the England-wide centres, which focused on improving access to primary care.

Located in a “health park” designed to host a range of services in one location for patients’ convenience, the centre sits next to an existing community hospital that has a minor injuries walk-in-service and will host an increasingly complex range of services in the future.

Financial implications

While Darzi centres became expensive duplications of primary and urgent walk-in care, the GPs here believe they will save vast sums of money for the local health economy by accelerating the shift of secondary care into the community.

Vose admits this is likely to destabilise hospital services but argues that it is a necessary byproduct of bringing more services into the community. He believes new clinical commissioning groups will aid this process, as GPs will be more willing to make “difficult decisions.”

“GPs are prepared to say, ‘It is tough, but you are going to have to cope with those services coming into the community, because there isn’t enough money to continue doing what you’ve been doing for the last 40 years,’” he says.

“We have the clinical knowledge to say ‘it is achievable,’ but the fallout from that could be destabilisation of hospitals.”

Tina Merry, senior partner at the practice, says this blueprint could be replicated elsewhere in the UK as commissioners seek to make savings and exploit the government’s drive for greater integration of services.

“It is the integrating agenda, it is developing services closer to home, and it is being more efficient. Secondary care consultants will come in here, and we will be able to work alongside them and work on pathway development to make sure we’re more integrated.”

A spokeswoman for the Royal United Hospital Bath NHS Trust, the closest district general hospital to the centre, says the trust is fully supportive of moves to move care into the community, which it says is “intrinsic” to its own five year business plan.

“Transferring some of our less acute work to alternative settings, such as the Frome Medical Centre, also means we can continue to provide high quality specialised acute services to an increasing number of patients who continue to need this type of care,” she said.

Nigel Edwards, senior fellow at the King’s Fund and former policy director at the NHS Confederation, says this may be true in rural areas but stresses the importance of commissioners taking a “nuanced and intelligent” approach to redesigning services and not being led by political dogma.

“In rural areas I can see a logic to this, as the travel distances are big. But done badly, this has the opportunity to fragment care and cause the hospital a cost problem without necessarily doing very much more than improving a bit of travel time for the patient.”

“My plea is to not get misled by these artefacts of accountancy, which is that the community tariff is cheaper than the hospital tariff. If it’s the same appointment with the same clinician, it’s costing you the same money really. It may look different, but the hospital still has the fixed costs that you’re now not paying for [if services are moved], which if you are the main purchaser of that hospital, is your problem too.”

In Frome, the GPs believe their new venture successfully navigates these pitfalls. Alongside NHS GPs and consultants, the integration is enhanced by the array of private treatment options for patients, including private physiotherapists, plastic surgeons, and acupuncturists.

As budgetary constraints make some surgical procedures increasingly difficult to access on the NHS, Vose argues that hosting NHS and private care in one place will offer patients valuable choice in how they access treatment. Around 5% of the space at the centre will be reserved for private practitioners, with 10% related to NHS outpatients.

He cites the removal of benign skin lesions, now restricted on the NHS, as an example of something that can be offered to patients privately on the spot if they don’t fit the treatment criteria, at a substantially lower cost than in a private hospital.

“We were talking to a plastic surgeon, and they were talking about benign skin lesions going down to between £400 and £500 [if done in the centre],” he explains.

“An outpatient appointment with a plastic surgeon just to say hello is £175, and booking any theatre space at a private hospital is probably about £1500. I think that’s a clever way forward and clever use of resources as you see more budgetary restraints coming onto commissioners.”

Meeting community needs

While Frome has paid careful attention to integration of services, this has not been the case with all incarnations of the polyclinic.

Candace Imison, deputy director of policy at the King’s Fund, who has conducted research on whether polyclinics improve integrated care, 6 predicts more centres like Frome will spring up as commissioners seek to save money. But she warns commissioners to avoid the trap that befell some Darzi clinics, which were “doomed to failure” because they were introduced regardless of local need.

“The big message from our research was that just putting things together in a building absolutely doesn’t facilitate integrated care.

“There are compelling reasons why you might want some of the constellations of services that exist within these clinics, such as better access to diagnostics, and chronic disease management. [But] the message is, redesign the work and then put the facilities in to support that. Don’t put the facility in and miraculously expect the work to redesign itself.”

The importance of proper planning and assessment is crucial—one of the criticisms levelled at Darzi’s polyclinics was that they destabilised primary care by diverting resources away from existing practices.7 This is less of a concern in Frome as the Beckington Family Practice—the only other practice in the town—will also be renting space in the new building, which should allow both practices to remain viable.

Some patients will have to travel further to the new centre, which the practice acknowledges has caused some concerns. This has led the Frome Medical Centre to retain its existing branch surgery on the other side of the town while other options are assessed. The practice is currently negotiating with the local bus company to extend its route to the new building, to offer smoother access for those unable to use the ample car parking space in the complex.

Imison predicts that clinical commissioning groups will see ventures like these as a way of providing care more efficiently, but she says they will have to be very cautious about how they develop services, given the parlous state of NHS finances.

“We can definitely expect a primary care led approach to care, and I imagine there will be a lot more of this sort of thing. But the pressure on money means people will be reviewing decisions a lot more closely,” she says.

After the excesses of the recent past, perhaps that’s not a bad place to start.

Notes

Cite this as: BMJ 2013;346:f343

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