Will polyclinics deliver real benefits for patients? Yes

Abstract

Government proposalstoestablish polyclinics are intended to reshape NHS services. Michael Dixon believes they will deliver more patient centred care, but Stewart Kay (doi: 10.1136/bmj.a130)thinks they are an unnecessary change

When asked by Department of Health advisers in 2005 to describe the future of primary care, the National Health Service Alliance and Small Practices Association suggested two models.¹ The first consisted of nested practices on a purpose built site providing conventional general practice services, extended primary care services, and some that are currently provided within secondary care. The second model—the virtual super surgery—envisaged practices working from their current premises but having extended primary care and diagnostic facilities either within the practices or in a central “resource and treatment” centre. This is similar to the federated practices model described last year in a report by the Royal College of General Practitioners.²

Both models are in line with government thinking on polyclinics. They provide the basis for some much needed integration between general practice, community, and secondary care services, which could provide patients with more cost effective, accessible, and better coordinated care.^{3 4}

Making polyclinics work

Several provisos are necessary to get these models right and personal discussions with Department of Health officials suggest these are also accepted by the centre. Firstly, that the development of such practice associations, whether on one site or virtual, should be led by the practices themselves as an organic process, supported by frontline practitioners and local people. Frontline clinicians should be emancipated and enabled to develop their local model, not have it imposed. The process, in junior health minister Ara Darzi’s words, should be “led from the bottom up.”⁵ Recent evidence warns of the dangers if the top is over prescriptive.⁶

Secondly, any proposals must guard against losing primary care’s hallmark qualities: personal care and continuity. More specifically, polyclinics should build on the registered list and good generalist care and seek to extend it rather than to undermine it.

Thirdly, polyclinics should maintain and indeed increase the NHS’s “horizontal” investment in whole person care rather than “vertical” investment in treating symptoms and diseases.⁷ This is because of the established importance of traditional primary care in terms of health outcomes, access, continuity, and lower cost⁸; hence any proposals must aim to strengthen primary care.⁹ Lord Hunt (first president of Royal College of General Practitioners) famously said that “integration was what the cat offered the canary,” which is why primary care clinicians must take a leading role (with secondary care colleagues) in developing proposals.

Thus defined, it is hard to argue against polyclinics offering a potential one stop shop that provides more integrated care and increased services, which are themselves more accessible and local to the patient. They represent the “missing link” when the NHS was created in 1948 and general practice continued on a separate path from the rest of the NHS. Primary care clinicians want more community diagnostics and a greater say in the services that their patients receive. Patients, meanwhile, want easier and quicker access and tax payers want more cost effective care. Practice based commissioning, as a potential means of bringing practices together, offers a bottom up mechanism for their creation.

Better public relations

So why the negative press? Partly, it is the name. Polyclinic has connotations of regimented queues outside an impersonal Soviet style concrete building. Indeed, the word “clinic” suggests a very biomedical approach, whereas the proposed primary care led polyclinics would have everything to do with personal relationships, self help, personal health, and improving community health. So perhaps we should change the name to “integrated centre.”

Next, there are media stories of general practitioners being herded into polyclinics according to some senior manager’s grand plan.¹⁰ Clinicians and patients rightly call foul when these plans seem to bludgeon general practice into submission rather than enable it to provide more. In a volatile political climate, where practices and primary care trusts are too often pitched against each other, where the rift between managers and clinicians seems to be getting wider rather than improving, misinterpretation and exaggeration and conspiracy theories are inevitable.

The unthinking implementation of rigid models by overzealous and overbearing managers, leaving clinicians angry and alienated, helps nobody. Proper implementation of the “polyclinic” idea should not be a sequence of orders from strategic health authority to primary care trust but a process of support for local practices to achieve their own integrated vision. Sadly, where they have done so, such as in Whitstable,¹¹ it has too often required a heroic struggle, and the NHS must get better at supporting them.

The answer is to get rid of the name, to be quite clear about what a polyclinic is and is not—frontline led partnership rather than takeover by secondary care or the private sector—and then liberate local practices and communities to develop their own version of integrated centres. Anything else is misguided and bound to fail. Nevertheless, if the idea behind polyclinics has been “lost in translation” that does not argue against the basic concept being sound.