The blind leading the blindBMJ 2007; 335 doi: https://doi.org/10.1136/bmj.39331.651250.59 (Published 13 September 2007) Cite this as: BMJ 2007;335:540
- Iona Heath, general practitioner, London
Ara Darzi is an eminent and respected professor of surgery at Imperial College London, and he is now a junior health minister in Gordon Brown's government. It is clear from the academic literature that he knows an immense amount about surgery in general and laparoscopic surgery in particular. However, tragically it is equally clear, from reading his vision for transforming health care in London, Framework for Action, that he has learnt nothing about general practice and primary care. Given the robust evidence that a strong basis in primary care improves the effectiveness and efficiency of healthcare systems, and when primary care is responsible for 82% of contacts with patients in the NHS, it must be asked who thought it could possibly be a good idea to ask a tertiary care specialist to redesign the provision of primary care.
The key part of Professor Darzi's plan is a network of “polyclinics,” each serving a population of around 50 000 people and within which GPs and specialists are to work side by side. This innovation is supposed to improve the integration of and accessibility to the health service in London, but this hope is vainly based on a profound misunderstanding of the utility of differentiating medical generalists from specialists. Generalists working at the point of first contact develop pragmatic skills that enable them to deal with the uncertainty that is inevitable when the prevalence of serious disease is low and to manage safely the vast majority of problems presented to them. Only 5% of GPs' consultations result in referral to specialist care; and this interface between primary generalist care and secondary specialist care marks a step change in the prevalence of serious pathology, which enables specialists to use costly investigations and skills in a focused and effective way.
The BMJ has received a perceptive rapid response to its initial coverage of the Darzi report, from Vasiliy Vlassov of the Moscow Medical Academy (www.bmj.com/cgi/eletters/335/7610/61-a). He points out that in Russia they know a thing or two about what happens when generalists and specialists are brought together to work in polyclinics: generalist skills are damaged because care is fragmented and continuity is disrupted; specialist skills are eroded by work with populations where prevalence is low and where the predictive values of symptoms, signs, and investigations diminish proportionately. Given the UK's recent track record of introducing sweeping change without piloting and evaluation, it becomes even more essential to pay some heed to the experience of others.
Framework for Action uses the simplistic vignettes that seem to have become compulsory in NHS policy documents, showing the imperfections of the present alongside the best of all possible worlds, which must inevitably result from the careful implementation of Professor Darzi's vision. The problem from the perspective of everyday general practice is that each patient in these stories has only one problem. Kishore has diabetes; Andrew has pneumonia. Unfortunately, the real test of a health service arises when one of these patients is also an alcoholic or has schizophrenia. The report makes no mention of the complex situations that are a daily occurrence in London general practice, involving patients who, while theoretically able to benefit from the provision of multiple services on a single site, are much more often frightened and intimidated and so find it easier to engage with local services on a more domestic scale and at a distance from large institutions.
The framework describes two possible locations for polyclinics, which are to be “more accessible and less medicalised than hospitals.” One location is “freestanding . . . in the community”; the other is “co-located with every hospital” as the “front door” to accident and emergency (A&E). Perhaps only a tertiary care consultant is able to see a polyclinic located at the front door of A&E as more accessible and less medicalised than the hospital itself. The scarcity and expense of vacant land in London makes the freestanding option less likely and the prospect of primary care controlled by hospital foundation trusts proportionately more so. In whose interests will this work?
The document has an admirable ambition of addressing health inequalities, and it explicitly acknowledges that the most deprived areas with the greatest health needs require better access to high quality health care. But, in the context of a plan that puts an emphasis on productivity, the problem remains that patients with the greatest needs will always need more time. Those on the losing end of health inequalities are much more likely to have multiple physical, mental, and social problems, each of which compounds the others. The report says that “mental health service users should be put in control,” but the emptiness of this rhetoric is underlined by the admission that advice on mental health services was taken from a group made up of 10 chief executives, one management consultant, one “development consultant,” and one race equality director. No clinicians of any sort were included, let alone any of the patients who are to be put “in control.”
Professor Darzi wants a “world-class healthcare system” for a “world-class city.” Unhappily, the city itself generates enormous socioeconomic inequalities, with obscene differentials in opportunity and life experience. No health service, however perfect, can prevent these differentials being reflected in the health of those who live them. Yet health inequalities are being used as the justification for reorganising health care and disrupting and further fragmenting general practice and primary care. Londoners have a much better chance of a decent health service through incremental improvements that build on those excellent services that already exist, rather than through the visions of a professor and a government neither of whom is able to see, let alone develop, the strengths and potential of generalist medical care.
In the context of a plan that puts an emphasis on productivity, the problem remains that patients with the greatest needs will always need more time