Intended for healthcare professionals

Feature Primary care

Polyclinics: haven’t we been there before?

BMJ 2008; 336 doi: (Published 22 May 2008) Cite this as: BMJ 2008;336:1161
  1. Virginia Berridge, professor of history
  1. 1Centre for History in Public Health, London School of Hygiene and Tropical Medicine, London
  1. Virginia.Berridge{at}

    Although integrated health care has been presented as a new idea, Virginia Berridge reveals that recent history tells a different story

    Ruth Carnall, chief executive of NHS London, said after the publication of the Darzi report on London’s health care last June that “This is the most ambitious and radical plan for the NHS in London since 1948.”1 The proposal that has attracted most media interest and public discussion is that of the polyclinic, typically the bringing together of a much wider range of services than that offered by most general practices. The Darzi report presents this development as something new in London and the UK. It cites an example from Europe, that of Berlin, to give an idea of how the polyclinic might work.

    But a look back into history shows that the idea of the polyclinic is hardly new. Rather, it is the resurfacing of an idea that had a long and interesting history in London and in national policy in the 20th century. The first incarnation was in the Dawson report of 1920. Dawson, a physician at the London Hospital, was asked to report overall on the health services by the newly established (1919) Ministry of Health, rather like Darzi has been asked to report by the government today.

    Dawson was in part inspired by the revolutionary changes in health care in the Soviet Union, where a system of polyclinics, bringing together specialist and other services, and based in local government, had been established after the October revolution.2 Dawson’s blueprint was a radical one. He envisaged replacement of the uncoordinated provision of the time by a network of primary and secondary health centres linked to district hospitals and then to regional hospitals. But the plan lacked political feasibility. Doctors relied on private fees or insurance payments through the panel system and resented the idea of becoming salaried employees of the state. The idea was costly and so never got off the ground.

    Pioneering reform

    It took on new life in London during the 1930s. The example which is often cited is that of the Pioneer Health Centre in Peckham. Run by the husband and wife team George Scott Williamson and Innes Pearse, Peckham operated according to a holistic model of health rather then disease, offering something akin to a modern health club, with swimming pool, gym, boxing rings, a dance hall, library, a crèche, and a café serving “compost grown” food produced at the centre’s own farm in Bromley. The Peckham idea was in fact predicated on the idea that there would be a parallel medical institution, the therapeutic centre, which would be run by general practitioners (GPs). Williamson thought that only GPs possessed sufficient information about the patient to make an accurate diagnosis and should therefore be given a central place.3 4

    Health centres were also part of the radical new developments in London’s health services during this decade. A municipal hospital service that was the largest in the world developed under the aegis of the London County Council after the end of the Poor Law in 1929. Local government ran the improved hospital service. Health centres were important, and the London boroughs were running them in the 1930s. In fact, as the historian of general practice Anne Digby has noted, the metropolitan boroughs led the way towards a new interwar form of delivery of primary health care.5 This was based on the model which Dawson had promoted. The purpose built centre in Peckham was joined by others in Bermondsey (1936), Finsbury (1938), Southwark (1938), and Woolwich (1939).Others planned for Camberwell and Kensington were not built.6 Bermondsey had a solarium for people with tuberculosis cases, dental clinics, foot clinics, and child welfare clinics. By 1946, it employed a psychologist, ran an additional orthopaedic clinic, had a radiology department, electromedical department, and consulting rooms for visiting specialists. Bermondsey was inspired by the GP and member of parliament George Salter and an Indian doctor, Dr Katial.

    The health centre idea was seen as potentially advantageous for general practice at this time. It would enable GPs to regain some of the territory which had been ceded in London and elsewhere to the medical officers of health and specialists. In the interwar years it looked as if local government and the medical officer of health (the local public health official) would be running any future form of organised state health service, GPs felt that they were often battling with them for the same territory as well as being squeezed by the consultant systems. The health centre was one way of repositioning themselves with a scientific and research role, while retaining access to the increasingly research based hospitals, where they did minor operations.

    Health centres remained central to the discussions about a national health service within government throughout the war. It is often forgotten that those discussions, and indeed the policy of the incoming Labour government elected in 1945, were based on the idea of a service which would be run by local government and funded by rates (local tax). It had the support of the key London politician Herbert Morrison and the health centre was seen as central. Abram Games famous 1942 poster of the Finsbury health centre was used to epitomise the postwar future.

    In 1942 the BMA’s medical planning commission accepted the idea of health centres but not under municipal control. Local government based plans were dropped by Aneurin Bevan as minister of health in the 1945 government because of opposition from GPs and consultants. Neither group wanted to work within a local government service as salaried employees. Bevan’s health service was a compromise, a tripartite service of hospital, general practice, and local government systems, the latter with only public health and social care responsibilities. But the health centre was the key unifying mechanism of the new service, bringing together the disparate arms and linking general practitioner services with public health departments. Historians have argued recently that the failure to integrate the centre more effectively in the new structures was a central drawback of Bevan’s NHS.7

    Implementation difficulties

    In the event few such centres were built or operated. GPs, who had been enthusiastic before the end of the war, stood aloof from them. After the NHS began only two fifths of those surveyed were in favour of the idea. The idea that the centres would take the patient away from the family doctor was common. Cost too was an issue. The new NHS was hugely more costly than government had estimated, mainly because the initial estimates had been made on the assumption that funding would mostly be at the local level, not from central government. Increased costs led to curbs on what were seen as unnecessary new building proposals.

    It was only in the 1960s and 1970s that the idea revived, in a very different form, as the group practice with attachment of ancillary staff such as health visitors.8 This time the context was the rejuvenation of general practice and the removal of public health from local government into the NHS. Public health no longer threatened the role of GPs at the local level and GPs could move into what had been public health territory. Only 28 health centres had been built between 1948 and 1967, but over the following decade over 700 were built.

    Learning from the past

    What can this history say about today’s plans for polyclinics? Some GPs were enthused about health centres, especially in the London boroughs. They saw a better way of delivering primary health care to sectors of the population who were disadvantaged. But GPs also saw something in the idea for themselves: a chance to raise the status of general practice, to carve out territory from public health, and to keep their specialist hospital connections. Some were enthusiastic at the inception of the NHS but support waned. The changes failed as a result of political backtracking because of cost and opposition from GPs who saw their status, income, and relationship with patients threatened.

    Map all those issues on to the present. Political support will be important, as will convincing GPs that there is something in the idea for them. In London, at a time when “new localism” (the idea of devolving more responsibility for communities to the local level)is in vogue and general practice is facing competition from commercial companies, there are opportunities to build on the achievements of the interwar London health service and the expectations of the early NHS. Could the polyclinic be an idea whose time has now come?



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