Polyclinics in England

Polyclinics in England were intended to offer a greater range of services than were offered by current general practitioner (GP) practices and local health centres. In addition to traditional GP services they would offer extended urgent care, healthy living services, community mental health services and social care, whilst being more accessible and less medicalised than hospitals.[1] A variety of models were proposed,[2][3] ranging from networks of existing clinics to larger premises with several colocated general practitioner (GP) practices, more extensive facilities and additional services provided by allied healthcare professionals.

The incoming health secretary in May 2010 Andrew Lansley put on hold all plans to increase numbers of polyclinics and to relocate GPs to them pending a review of policy under the new coalition government,[4] after a review by management consultants McKinsey revealed "NHS managers had vastly overestimated the ability of polysystems to handle the shift in care from hospitals and revolutionise GP care".

Operational polyclinics

On Wednesday 29 April 2009, the first seven polyclinics in England opened in London, marked by the opening of the Loxford Polyclininc by Lord Darzi. The seven were:[5][6]

  • Redbridge Primary Care Trust: Loxford Polyclininc[7][8] (the first purpose-built polyclinic)[5]
  • Harrow Primary Care Trust: Alexandra Avenue Health and Social Care Centre[9]
  • Hounslow Primary Care Trust: Heart of Hounslow[10]
  • Lambeth Primary Care Trust: Gracefield Gardens Health and Social Care Centre[11]
  • Waltham Forest PCT: Oliver Road Polyclinic[12]
  • Tower Hamlets Primary Care Trust: The Barkantine Centre[13]
  • Hammersmith and Fulham Primary Care Trust: Hammersmith Centre for Health at Hammersmith Hospital[14] (London's first hospital-based polyclinic)[5]

Polyclinic services

The polyclinic model proposed in London will provide:

The government accepts that the polyclinic model may not be suitable for rural areas but may be popular in the larger conurbations.

History

Health centres offering a mix of community-based health care services have existed in England since the early years of the National Health Service (NHS). They have typically provided specialist care such as ophthalmology, podiatry, dentistry, minor injuries nursing, and therefore provided services that fell between that of the GP service and those available at the hospital.

Some primary care trusts in England attempted to bring together even more services into such centres, most notably by co-locating GPs, health laboratories, pharmacies and other services under one roof. The Heart of Hounslow Centre for Health for example has GP services, outpatient care, physiotherapy, dentistry, podiatry, social care outreach, mental health services for children and a gym to help in rehabilitation. All these services take place in a purpose-built facility.[15] However, the centre does not provide urgent care and only has a limited range of diagnostics.

Polyclinics were proposed only for London by Professor the Lord Darzi of Denham in his review of healthcare in London for NHS London: Healthcare for London: A Framework for Action.[1] In the final report of his subsequent national review for the Department of Health, High Quality Care for All[16] Lord Darzi has not suggested that polyclinics would be appropriate elsewhere; instead he suggests "GP-led health centres". He explained the difference between the two models to the House of Commons Health Select Committee on 19 July 2008.[17]

A key principle of A Framework for Action is to "localise where possible, centralise where necessary." This would move "routine healthcare" away from acute hospitals and into community-based centres to provide a one-stop-shop for health care. "More complex care" would remain centralised. A key part of the plan is to extend the opening times of such centres, especially in the evenings, to make them more accessible to working people.

While polyclinics had not been widely implemented across England prior to 2008, they have existed in Australia, France, Germany (since 2004), Northern Ireland, Switzerland and Russia;[18] and in many countries across Asia and Africa, although several of these countries are now seeking to remove them.[19] In Russia, where they were introduced under communism, attempts were made to replace them with a more western model by the new Russian government. However, the Russian polyclinic model proved robust and the authorities' prescriptive interference failed.[20]

Rationale

The Department of Health and the government claimed that polyclinics offer:

  1. A way of providing more services in the community closer to home and at more convenient times (including antenatal and postnatal care, healthy living information, community mental health services, community care, and social care and specialist advice)
  2. An improved structure within which GPs and other health and social care professionals can work together
  3. Improved care for patients with chronic or complex conditions
  4. A shift in the focus of urgent care out of hospitals and into polyclinics.[18]

A report by the King's Fund has questioned many of these, observing that:

  1. Access to services was likely to be harder in rural areas and in urban areas where new buildings were not situated close to transport hubs
  2. Simply putting healthcare professionals in the same location is in practice often not sufficient to generate co-working or integration of care
  3. While the co-location of multiple services presents opportunities for delivering more integrated care, particularly for people with chronic diseases, the evidence suggests that in practice these opportunities are often lost, and accessibility of primary care is likely to be reduced for most patients if their GPs move into polyclinics, particularly in rural settings (a point emphasised in The Times[21])
  4. There is limited evidence that quality of care for services shifted out of hospitals is comparable, and there is evidence that quality may be decreased in certain cases; the limited inspection and accreditation of out-of-hospital care is also a serious deficit in quality assurance

The report also observed that the proposals were likely to increase professional isolation, and threaten both professional development and motivation, and continuity of care, and that pre-existing problems in healthcare to do with the lack of an overall governance structure, and unclear lines of accountability had not been addressed.

It concluded that while polyclinics offered real opportunities for some health communities to establish more integrated, patient-focused care, these would only be realised with considerable investment of time, effort and resources into their planning and development, and that the primary focus should be on developing new pathways, technologies and ways of working rather than new buildings.[22]

The Conservative Party leader David Cameron did not object in principle to the case for polyclinics but is worried that they might be imposed against the wishes of communities. He suggested that close to 1,600 GP surgeries may have to close across the country as a whole if polyclinics were established in the way the government is suggesting.[23] The Health Minister Ben Bradshaw, however, denied that individual GP practices would be closed as patients would remain registered with their existing GPs.[24] These figures have also been dismissed[25] by Dr Laurence Buckman, chair of the British Medical Association's General Practitioners Committee.

Funding

It was unclear whether polyclinics would be funded in addition to existing GP services or whether they will take funding away from existing practices. Although Lord Darzi claimed that their funding would be in addition to existing funding,[26] following the publication of his report, eight London primary care trusts drew up plans to relocate more than 100 urban GP surgeries into polyclinics.[27] The Conservative Party claimed that unless existing surgeries close, polyclinics will leave a £1.4 billion "black hole" in public finances.[28]

Implementation

Polyclinics were originally planned for and implemented in London, with every primary care trust in the country subsequently required to have at least one new "GP-led health centre".[24][29][30] All of the first wave of polyclinics in London, which formed a pilot of the model, were of the federated/networked model and involved "existing services working more closely together".[31]

As of August 2008, more than a quarter of PCTs had plans to implement a polyclinic or GP-led health centre,[32] including Birmingham, Cumbria, Lincolnshire, Rochdale, Cheshire, Essex and Bolton. More than 50 PCTs admitted that they would not consult local communities over plans to build polyclinics, some citing advice from the Department of Health as the reason, despite repeated government promises that they would not be introduced without consultation.[33]

The country-wide rollout of GP-led health centres was criticised by doctors' leaders and patient groups. Dr. Richard Vautrey, deputy chairman of the BMA, called it "a government plan that is potentially going to waste hundreds of millions of pounds of scarce NHS resources, creating very large health centres that many areas of the country simply don't need or want",[34] while the Patients Association noted that gathering services under one roof in rural areas "may actually put patients at risk" and noted that rural patients already had to travel further and were more reliant on primary care.[35] The other political parties have also criticised it, with the leader of the Liberal Democrats Nick Clegg calling it "the central imposition of a polyclinic on every primary care trust, regardless of the geography, demographics and clinical needs of the area" while acknowledging that they might be a good thing for people in some communities[36] and Conservative leader David Cameron suggesting large-scale closures of existing GP surgeries.[23]

The results of a freedom of information request by Pulse on the plans for polyclinics show that nursing staff could outnumber doctors by up to three to one. The BMA said the plans would lead to "cut-price general practice". A spokesperson for the Department of Health said "where people choose to register with a GP-led health centre, they should expect the same quality and continuity of care from GPs and other primary care clinicians as they would from any other GP practice".[37][38]

On 10 September 2008, an NHS London press release[39] and fact sheet[40] announced details of 5 of a possible 13 polyclinics in the first wave in London.[41] They were to be developed by the following primary care trusts:

  • Harrow PCT: Alexandra Avenue
  • Hounslow PCT: Heart of Hounslow
  • Lambeth PCT: Gracefield Gardens
  • Redbridge PCT: Loxford Centre
  • Waltham Forest PCT

Also anticipated in the first wave were:[41]

  • Camden PCT: Four federated polyclinics
  • Haringey PCT: Currently rethinking plans to close 37 surgeries
  • Kensington and Chelsea PCT: Five surgeries to be relocated to polyclinic hub at St Charles Community Hospital

Opinion

Opinion on the plans for polyclinics was polarised.

Polyclinics are based on long term trends of what works best in healthcare, and in fact there are many practices successfully operating under a similar model already. As such we have been genuinely surprised to see the level of concern surrounding these proposals among the health community and patient groups. What we need now is a calm and balanced debate about how to bring out the best in our primary care services. The name may pose a problem. Polyclinics may be associated with the previous soviet system of healthcare, however what is proposed here has no real connection to this at all. While it may sound like the polyclinic system will not resemble the service currently provided by family doctors, in reality it should build on what is best in general practice. Of course this is not something that will work in every circumstance, but delivering better organised care focused on the patient is surely a good thing. This is why it is crucial that politicians and health professionals fully engage with the benefits that polyclinics can bring. Knee jerk reactions focussing on possible problems based on pre-existing agendas rather than potential solutions could seriously jeopardise progress for patients.

With HIV now a long-term condition, polyclinics have a very important role in the delivery of HIV care. Many routine services, such as regular blood tests and check ups shouldn't require a trip to a hospital-based clinic. Integrating services can only make life easier for people living with HIV so it's definitely a welcome move.[39]

  • Samantha Mauger, Chief Executive of Age Concern London, said:

We welcome the intention of providing an integrated local health centre delivering a wide range of services in a joined-up approach. If this is done with care it could benefit many older people. While older people may be worried about possible changes to the services they currently use, many suffer at present from lack of coordination between different health and social care services. The NHS needs to work with and listen to local people's views about the services to be provided. We need improved, responsive services and easy access for Londoners of all ages from all communities.[39]

Polyclinics were a centrepiece of the Soviet model of healthcare delivery, but many countries of Central and Eastern Europe have abandoned them over the past two decades in favour of a system of general practice that draws extensively on the British model. Advisers from the World Bank, the EU, and many bilateral donors agreed that the polyclinic had failed to deliver modern, integrated health care and saw general practices as the future.[47]

  • The British Medical Association was opposed to polyclinics from the start, observing that larger clinics were already emerging where needed, that forcing their introduction was wasteful and costly, and that they would undermine the value of a relationship existing between GP and patient.[48] They have further commented that the design of the proposals appears deliberately to disadvantage existing GPs from applying to run the clinics, leaving the way open for privatisation of GP services.[49]
  • A significant proportion of the general public are opposed to polyclinics, with more than a million signing the British Medical Association's petition against them.[50] Press reports suggested that they were unpopular with patients, particularly the elderly, who feared polyclinics would ruin their relationship with their doctor and were finding they had to travel further to see a doctor.[51] However, of the 4,372 individual responses and 359 organisational responses to NHS London's official consultation, 51% supported the proposal that "almost all GP practices in London should be part of a polyclinic, either networked or same-site".[52][53] The consultation noted that some respondents were concerned about the effect of polyclinics on the GP-patient relationship, worse continuity of care, possible extra travel time, cost, governance, and whether the money would be better spent on improving existing services.[54]
  • The Patients Association was concerned that polyclinics could jeopardise the patient-doctor relationship which they regard as a central plank of effective and personalised care and as "central to every patient's experience of healthcare", particularly in those with long-term or complex conditions. They also observed that polyclinics are not necessary to providing one-stop care, something already delivered in the NHS at one stop shops, and that they are likely to lead to the loss of other health services in rural areas.[35]
  • The Liberal Democrats criticised polyclinics as part of the government's "obsession with imposing models of care from the centre", noting that this flies in the face of their "rhetoric on local decision-making".[48]
  • The NHS Alliance called polyclinics "lost in translation", commenting that while they are good when implemented in the right way, this "means general practices locally deciding to integrate their services" with willingness from both doctors and local people. "The BMA and patients are afraid that they might be losing the good bits of general practice – and the way that polyclinics have been implemented in some places means they have got a point."[50]
  • The Royal College of General Practitioners, who support the notion of GPs working in federations,[55] have nonetheless condemned the government's plans for polyclinics, and have set out their own proposal for "Primary Care Federations",[56][57] saying "GPs and patients must be involved in the planning, and we cannot afford for existing high quality GP practices to be destabilised".[50]
  • Opinion pieces for The Guardian have differed dramatically in tone. Polly Toynbee suggested that "it's hard to see a downside for patients" and GPs' protests are "all about profits, not patients",[58] while George Monbiot called it the "outright privatisation of primary healthcare" and suggested it would make primary care "more expensive and less efficient" and see "those who can't afford to pay are either excluded or treated like battery pigs".[59]
  • The Independent included a balanced article on them, explaining the possible benefits and disadvantages.[60]

External references

References
  1. Professor the Lord Darzi of Denham KBE (11 July 2007). "Healthcare for London: A Framework for Action" (PDF). NHS London. Archived from the original (PDF) on 27 December 2008. Retrieved 17 August 2008. Cite journal requires |journal= (help)
  2. Professor the Lord Darzi of Denham KBE (11 July 2007). "Healthcare for London: A Framework for Action, p.93" (PDF). NHS London. Archived from the original (PDF) on 27 December 2008. Retrieved 17 August 2008. Cite journal requires |journal= (help)
  3. "Healthcare for London: Consulting the Capital, p.41" (PDF). NHS London. 30 November 2007. Archived from the original (PDF) on 30 December 2008. Retrieved 18 August 2008. Cite journal requires |journal= (help)
  4. Ian Quinn (21 May 2010). "Lansley orders halt to all Darzi plans nationwide". Pulse.
  5. Pioneering polyclinics to transform patient care across London
  6. "Seven polyclinics open in London". BBC News. 29 April 2009.
  7. Loxford Polyclinic
  8. "59 consulting rooms, a gym and a café in the new super-surgery". Archived from the original on 2 May 2009. Retrieved 2 August 2009.
  9. Alexandra Avenue Health and Social Care Centre
  10. Heart of Hounslow
  11. Gracefield Gardens Archived 7 September 2012 at Archive.today
  12. Oliver Road Polyclinic Archived 31 August 2009 at the Wayback Machine
  13. The Barkantine Centre
  14. Hammersmith Centre for Health
  15. Victoria Vaughan (6 September 2007). "London unveils first polyclinic". Health Service Journal. Archived from the original on 7 January 2009. Retrieved 5 September 2008.
  16. Professor the Lord Darzi of Denham KBE (30 June 2008). "High Quality Care for All: NHS Next Stage Review final report". Department of Health. Retrieved 17 August 2008. Cite journal requires |journal= (help)
  17. "Uncorrected transcript of oral evidence to the House of Commons Health Select Committee". Hansard. 17 July 2008. Retrieved 4 September 2008.
  18. NLH – Health Management – Polyclinics. Retrieved 3 July 2008.
  19. Lakhani, Prof. Mayur; Baker, Dr. Maureen; Field, Prof. Steve (2007). The Future Direction of General Practice – a roadmap (pdf). London: Royal College of General Practitioners. ISBN 978-0-85084-315-6. Retrieved 3 May 2015.
  20. Ershova, I; Rider, O; Gorelov, V (December 2007). "Polyclinics in London". Lancet. 370 (9603): 1890–1. doi:10.1016/S0140-6736(07)61793-0. PMID 18068500. S2CID 43512994.
  21. Keith Hopcroft (12 June 2008). "What is wrong with polyclinics? Try the death of GP care". The Times. London. Retrieved 3 July 2008.
  22. Imison, Candace; Naylor, Chris; Maybin, Jo (5 June 2008). Will polyclinics deliver integrated care?. The King's Fund. ISBN 978-1-85717-569-1. Archived from the original on 14 June 2008. Retrieved 3 July 2008.
  23. David Cameron (21 April 2008). "David Cameron: Speech on Primary Care". Archived from the original on 8 June 2008.
  24. "GPs fears about polyclinics". 28 July 2008. Archived from the original on 6 August 2008. Retrieved 24 August 2008.
  25. "Row breaks out over polyclinic impact on nearby surgeries". Pulse. 25 August 2008. Retrieved 27 August 2008.
  26. "No GP surgeries will close". BBC News. 6 July 2008. Retrieved 24 August 2008.
  27. Anna Davis (28 May 2008). "100 GP sites facing axe under polyclinic plans". Evening Standard. Archived from the original on 29 May 2008. Retrieved 18 August 2008.
  28. Sara Gaines (11 June 2008). "NHS polyclinic plans will leave £1.4bn black hole, Tories claim". London: The Guardian, Comment is Free. Retrieved 18 August 2008.
  29. "House of Commons Hansard Debates for 17 Jun 2008 (pt 0007)". Hansard. 17 June 2008. Archived from the original on 5 June 2011. Retrieved 24 August 2008.
  30. Rose, David (12 June 2008). "Doctors' leaders claim patients will suffer from polyclinics plan". The Times. London. Retrieved 24 August 2008.
  31. Dave West (4 September 2008). "London denies polyclinic U-turn". Health Service Journal. Retrieved 4 September 2008.
  32. "Darzi polyclinics just the tip of the iceberg as second wave revealed". Pulse. 12 August 2008. Retrieved 24 August 2008.
  33. Donnelly, Laura (3 August 2008). "Polyclinics will be imposed despite ministers' promises". The Sunday Telegraph. London. Retrieved 25 August 2008.
  34. Alford, Simon (16 February 2008). "Polyclinics to replace traditional doctors' surgeries". [The Times]. London. Retrieved 25 August 2008.
  35. "Polyclinics". The Patients Association. Archived from the original on 27 August 2008. Retrieved 3 July 2008.
  36. Graham Tibbetts (10 June 2008). "Nick Clegg: Polyclinics are being imposed across country". The Daily Telegraph. London. Retrieved 24 August 2008.
  37. Gareth Iacobucci (10 September 2008). "Nurses to outnumber GPs three to one in Darzi centres". Pulse. Retrieved 10 September 2008.
  38. Kate Devlin (10 September 2008). "Polyclinics 'will contain three nurses to every GP'". The Daily Telegraph. London. Archived from the original on 10 September 2008. Retrieved 10 September 2008.
  39. "Transformation of London's healthcare begins" (Press release). NHS London. 10 September 2008. Retrieved 11 September 2008.
  40. "Polyclinics in London – fact sheet" (doc). NHS London. 9 September 2008. Retrieved 11 September 2008.
  41. "First polyclinic will serve 50,000 patients". Pulse. 16 September 2008. Retrieved 17 September 2008.
  42. University of Manchester – School of Medicine – Professor Martin Roland CBE Archived 12 February 2007 at Archive.today
  43. BBC News (21 March 2008). "Hospital and GP reforms 'flawed'". BBC News. Retrieved 23 March 2008.
  44. Nancollas CE (April 2008). "Doctors warn of premature move to polyclinics: Joined-up thinking?". BMJ. 336 (7647): 736. doi:10.1136/bmj.39535.425139.1F. PMC 2287242. PMID 18390503.
  45. Batty, David (11 July 2007). "Health experts condemn London polyclinic plans". The Guardian. Retrieved 22 May 2010.
  46. O'Dowd A (March 2008). "Doctors warn of premature move to polyclinics". BMJ. 336 (7645): 635.1–635. doi:10.1136/bmj.39521.479618.DB. PMC 2270948. PMID 18356228.
  47. Rechel, Bernd; McKee, Martin (2008). "Lessons from polyclinics in Central and Eastern Europe" (PDF). British Medical Journal. 337 (7663): 236. doi:10.1136/bmj.a952. JSTOR 20510425. S2CID 71379674.
  48. Asthana, Anushka (17 February 2008). "GPs' leader hits out at plans for Soviet-style 'polyclinics'". The Observer. London. Retrieved 3 July 2008.
  49. "Doctors fear 'GP privatisation'". BBC News. 26 December 2007. Retrieved 6 July 2008.
  50. O'Dowd A (June 2008). "More than a million people signed petition against polyclinics". BMJ. 336 (7658): 1399.2–1399. doi:10.1136/bmj.a375. PMC 2432154. PMID 18559361.
  51. Brendan O'Neill (1 July 2008). "Editorial: I don't want any more 'patient choice'!". Spiked. Retrieved 3 July 2008.
  52. "Healthcare for London – Consulting the Capital update" (Press release). NHS London. 6 May 2008. Retrieved 19 August 2008.
  53. "Londoners back polyclinics, survey shows". Health Service Journal. 7 May 2008. Retrieved 14 August 2008.
  54. "Report on the consultation and recommendations for change" (PDF). NHS London. Archived from the original (PDF) on 30 December 2008. Retrieved 25 August 2008.
  55. "Debate: Do patients want polyclinics?". Pulse. 3 September 2008. Retrieved 4 September 2008.
  56. "Primary Care Federations – Putting patients first" (PDF). Royal College of General Practitioners. June 2008. Archived from the original (PDF) on 22 July 2011. Retrieved 4 September 2008. Cite journal requires |journal= (help)
  57. Royal College of Physicians, Royal College of General Practitioners & Royal College of Paediatrics and Child Health (11 April 2008). "Teams without Walls: The value of medical innovation and leadership" (PDF). Royal College of Physicians. Archived from the original (PDF) on 21 October 2008. Retrieved 14 August 2008.
  58. Toynbee, Polly (6 June 2008). "Don't be fooled: this doctors' protest is all about profits, not patients". London: The Guardian, Comment is Free. Retrieved 14 August 2008.
  59. George Monbiot (29 April 2008). "Labour's perverse polyclinic scheme is the next step in privatising the NHS". London: The Guardian, Comment is Free. Retrieved 18 August 2008.
  60. "The Big Question: What are polyclinics, and why are doctors so angry about them?". The Independent. London. 13 June 2008. Retrieved 14 August 2008.
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