News

King’s Fund says advantages of polyclinics often lost through poor implementation

5 June 2008

A King's Fund report published today says that poor implementation of the polyclinic model could create significant risks for patient care. The report [1] studies the opportunities and risks of developing polyclinics in England.

Government proposals for polyclinics, which have been discussed as part of Lord Darzi’s NHS Next Stage Review, could bring together family doctors and specialists alongside other services, such as diagnostic testing, minor surgery, blood tests and x-rays into new purpose-built buildings.

The term polyclinic has been used to describe a variety of different approaches from very large super surgeries, which involve closing current GP practices and moving their services into the new unit, to the so-called hub-and-spoke model where most existing practices continue but share access to a set of new services in one facility. The King’s Fund report concentrates on the ‘big building’ model and examines the impact they would have on patient care.

The report examined existing facilities similar to the polyclinic model built in England using the NHS Local Improvement Finance Trust (LIFT), a capital procurement programme that enables the development of new primary care premises. Researchers found that despite bringing professionals together under one roof, in high quality facilities, the absence of clear local leadership, integrated managerial structures, or shared information systems, meant that integrated care had remained elusive.

Most facilities had been unable to break longstanding divisions between GPs and specialists — with family doctors remaining independent contractors, community staff accountable to distant managers, and specialists firmly rooted in their host hospitals. In addition, limited enthusiasm from GPs and consultants had hampered the development of the facilities — GPs had often been reluctant to move into the new centres, where they faced a loss of autonomy and control over their practice’s biggest asset, its building.

Shelton Primary Care Centre, Stoke on Trent. The £8m centre was opened in May 2008 on the site of a derelict pottery. It amalgamates three local GP practices, giving about 15 GPs on site. It also provides midwifery, psychiatric nursing, family planning, health visiting, podiatry, child health, minor surgery, asylum seeker and refugee medical screening, cervical cytology screening, phlebotomy, chronic disease management, speech and language therapy outpatient services and a pharmacy.

There is strong opposition to polyclinics among GPs, and the BMA recently launched a campaign against them, claiming that they could damage primary care (see bjhc&im news: GPs campaign against polyclinics). GPs fear that there is a government campaign for privatisation of primary care at the expense of the existing GP services.

On BBC Radio 4's Today programme this morning Dr David Colin-Thomé, National Clinical Director for Primary Care, said the opposition was "a BMA thing". He also said that there is "no imposition of a master plan" and that development of services will be a "local decision where the local primary care trust will be talking with the public". He also said that there was a misconception that 152 polyclinics would be imposed on primary care trusts across England. These are not polyclinics but new general practices, he said, with extended hours and could have extra services determined locally, such as diagnostics and x-rays.

In Bristol the Primary Care Trust has built two new health centres under a public-private partnership using LIFT and is due to start on the £45m South Bristol Community Hospital, pending planning permission. All three facilities will be leased from Bristol Infracare LIFT Ltd, a public-private partnership set up to run the facilities. Both the hospital and one of the health centres, Whitchurch Health Centre, will perform minor operations in competition with the local hospitals.

A Bristol GP told bjhc&im that there were already adequate GP and hospital services in Bristol, including a major teaching hospital, and that the centres were built despite local GP opposition. The GP claimed that the provision of minor operations would undermine the local hospitals because they would cream off the simple, profitable operations that are a major source of income. In addition it would severely damage the ability of the teaching hospital to train new surgeons as the type of operations carried out in the new clinics are exactly those used for training.

The Bristol PCT website says that "Local people have told us they want this hospital". This oft-quoted claim that local people say they want these new services also rankled the Bristol GP, who claimed that there is no way of knowing how this so-called "demand" by local people was derived and that it seemed to be a cover-all to impose the new services over the GPs.

It is hardly surprising that the GPs are up in arms — and the BMA is only reflecting GP opinion — when it appears that the government is failing to take GP opinion into account, using a woolly claim of fulfilling the public's demands.

The report's findings in detail

The King's Fund says it welcomes the government’s ambition to develop more patient-focused and integrated models of care but warns that poor implementation of this model could create significant risks for patient care. Its key findings are:

• Quality of care: polyclinics could help to redesign services around the needs of patients and deliver integrated care, particularly for people with long-term conditions. However, the evidence suggests that in practice these opportunities are often lost — bringing together multiple services does not always result in better working practices between professionals, and there is no evidence that larger GP practices deliver higher quality care than smaller ones although they may be able to offer a wider range of services.
• Accessibility of services: for some patients access to diagnostic and other services would improve and the impact would vary depending on how large and centralised the polyclinic would be. However, a major centralisation of GP services into polyclinics would make it more difficult for patients to visit their GP, especially those living in rural areas. This would be a major sacrifice given that primary care visits account for 90% of all patient contact with the NHS, and that patients are less prepared to travel further to see their family doctor than they are to use outpatient and hospital services.
• Costs: while there is a strong case for providing more support in the community to prevent hospital admission there is substantial evidence that shifting some specialist services out of hospital can prove more expensive. In these cases services can be less efficient and often fail to reduce demand on hospitals, so that the costs of new services supplement rather than substitute for hospital costs.
• Workforce: the successful examples of integrated care delivered in polyclinics abroad may not transfer easily to the NHS in England due to important differences in the medical workforce. Here most specialists are based in hospitals not the community as they often are abroad. The European Working Time Directive and changes to postgraduate medical training will place further demands on specialists’ time. Some of the polyclinic models of care therefore presents significant workforce challenges.

Report co-author Candace Imison said: "There is a strong case for challenging the way we organise health care in England. For some health communities the development of polyclinic-type facilities could offer great opportunities to establish more integrated care that delivers real benefits to patients. But these benefits will only be realised if the focus is on changing the way we deliver care, not just changing where care is delivered."

King’s Fund Chief Executive Niall Dickson added: "Our model of health care has changed little since the NHS began 60 years ago — advances in technology, changes in the composition and working hours of staff, as well as patient expectations and evidence about what is effective, all signal the need to review how and where care is delivered. The polyclinic approach could be one way to redesign services around the needs of patients but we must not underestimate the amount of time, energy, and resources that would needed to make it work.

"We welcome the government’s assurance that there will be no national blueprint but that needs to be spelt out in unequivocal terms. Above all we appeal to ministers to make it abundantly clear that there will be no compulsion on local NHS organisations to erect buildings or follow this or any other centrally dictated model of care. Polyclinics may be the right answer in some areas, they will not be right for others. That should be a matter to be decided locally on a case-by-case basis using the best clinical evidence available together with a full assessment of the costs and the impact on patient access."

The report’s analysis of polyclinics suggests that local planners should be careful to assess the benefits and costs of the polyclinic approach. Its recommendations aim to provide guidance for local NHS services and commissioners on realising the opportunities and avoiding the risks of introducing these new models of care:

• Primary care trusts (PCTs) should proceed with polyclinics only where benefits to local communities in terms of quality, access and costs are clear. The primary focus should be on developing new care pathways, using technologies to improve patient care and better joint working across teams and professions. Developing new facilities may form a part of the strategy, but buildings should be a means to an end, not an end in themselves.
• PCTs should consider alternative polyclinic models which do not require mass centralisation of family doctor services, such as the hub-and-spoke or federated model where most GPs remain in their premises and draw on resources in a central polyclinic or resource centre.
• Strong clinical and managerial leadership supported by clear governance structures will be necessary. Polyclinics will also require workforce planners at the national and local level to explore and address the workforce implications as a matter of priority.

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