News / Poly folly?

When it comes to polyclinics the only thing anyone seems able to agree on is that little can be agreed about them. They have been described as an exciting initiative that will deliver hitherto hospital-based services on patients’ doorsteps, and a waste of money that will duplicate hospital care. They are seen as a money-saving exercise and a scheme that will raise costs.

And that’s before the debate over which services should go into them or whether they should be freestanding buildings, units based on hospital campuses or a group of GP practices linked together in a virtual polyclinic. 

Despite this degree of confusion, local NHS organisations have been setting up their own polyclinics. Primary care trusts in Liverpool, Birmingham and Sunderland, for example, have launched polyclinic plans. Many PCTs could argue they have been setting up polyclinics over the past few years.  ‘One-stop shop’ health centres with co-located GP practices, social services, a pharmacy and GPs with special interests have been a feature of many PCTs’ primary care estate development.

Since Lord Darzi’s interim report on the future shape of the NHS in England last October, which made polyclinics de rigueur, the focus has been on London. Last summer he published a similar review and recommended a network of 150 polyclinics across the capital. NHS London is currently developing at least 10 pilot sites and all London’s PCTs are expected to commission either a polyclinic or an additional health centre in 2008/09.

As early as last September, the board of University College London Hospital NHS Foundation Trust discussed setting up a polyclinic on its site. This would incorporate accident and emergency and outpatients.

Policy from the centre and actions by local NHS bodies mean the health service is already developing polyclinics, yet many of the key players are unconvinced. The British Medical Association (BMA) and the Patients’ Association (PA) have both been critical of Lord Darzi’s ‘big idea’. The BMA said they were inefficient because they would create too much capacity and the PA said they were a cost-saving exercise.

However, if they are to generate savings, polyclinics are more likely to be a ‘spend to save’ exercise. For example, last year Liverpool Primary Care Trust promised investment of £100m in three NHS treatment centres that will move diagnostic and therapy services out of hospital. These will be complemented by a network of neighbourhood health centres, offering a greater range of primary and community services. The PCT said by the time the programme ends in 2014 no-one would be further than 15 minutes walk to a GP. The capital development would signal the ‘end of the era of the run-down terraced house surgery’.

Last month the NHS Confederation gave its broad support for polyclinics. It is concerned the benefits polyclinics could offer patients will be lost among the din of criticism. ‘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,’ said Nigel Edwards, the Confederation’s director of policy. 

‘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.’

The main reason for pursuing polyclinics was not to generate savings but to improve the quality and effectiveness of services for patients. In its report Ideas from Darzi: polyclinics the Confederation said there was little evidence that out of hospital care was cheaper. Savings made by moving from outdated buildings to appropriate, modern ones were often swallowed up by the costs of capital on the new buildings.

But the polyclinics idea was not just about smart new health centres – creating seamless services within new or existing buildings was more important, and these could generate savings.

‘There is stronger evidence that well-organised and integrated systems improve cost-effectiveness, reduce follow-up appointments, reduce duplicated tests and improve the quality of care. These may produce savings, some of which may be “cashable”,’ the report added.

Despite the Confederation’s efforts, Dr Laurence Buckman, chairman of the BMA’s GPs’ committee, remained critical. He was worried the new polyclinics would be procured under APMS (alternative providers of medical services) contracts – the route used to bring in private healthcare providers into primary care.

‘This commercialisation of patient care in the community is the very opposite of the personalised care that the government espouses and which family doctors already provide,’ he said.

Though it is keen to publicise the benefits of polyclinics, the Confederation also has some concerns about how they might operate. Its report warned that there was a danger in creating extra capacity – it might lead to more activity with little benefit or simply replicate existing services, whether in the primary or secondary sector. The average cost of treatments may fall but this could mask a rise in the overall cost.

The report insisted that additional, polyclinic-based services had to be thought through – and if it was a substitute for existing services, they had to be reduced correspondingly.

But why would hospital trusts accept this run-down of their services and the ensuing loss of income? The report called for greater flexibility in the way trusts received their income. ‘There are solutions, but the tendency to treat the tariff as though it is written in stone is a problem here,’ it said.

The starting point should be to choose the right clinical path and share the gains, rather than sticking rigidly to the tariff, it added. ‘Gainsharing, transitional relief (subject to the constraints of the competition code) and a variety of other mechanisms are available to deal with this, but it requires high-quality and mature relationships.’

A flexible approach may also be needed to set up polyclinics in rural areas. NHS Alliance chairman Dr Michael Dixon’s College Surgery has set up its own polyclinic, the Integrated Centre for Health, in Devon. Ten GPs offer a range of services out of the building, as well as operating three branch surgeries in neighbouring villages.

Dr Dixon said: ‘Practices need increasingly to work with each other and with other partners in primary care, whether as virtual partners or on one site. But there should not be a single template.’

Polyclinics’ time appears to have come but some barriers stand in their way. There is some concern about PCT management capacity – NHS London’s March board meeting heard that it was ‘likely’ there would be ‘insufficient leadership capacity in PCTs and allied NHS organisations’ to implement Darzi’s reforms. Despite the 2006 reorganisation and fit for purpose reviews, there are said to be similar concerns about PCTs in other parts of the country.

Doctors’ cooperation will be needed if the polyclinic initiative is to succeed but a transparent funding regime will also be vital to incentivise trusts to move treatments out of hospital.


Comment on this article