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Health minister's NHS facelift plan sparks division among GPs

By Steve Nowottny

It is five minutes into the launch event for a massive proposed shake-up of health services in London, and the report's author – new health minister Professor Sir Ara Darzi – is not a happy man.

Pressed by reporters for the bottom line – whether his plans to shake up the NHS system in the capital will mean closures for hospitals and GP practices – he shakes his head sadly.

'It's disappointing when you've taken an eight-month journey, with all the clinical communities going through this journey,' he says. 'The word closure doesn't feature anywhere here.'

It is, though, a fair question and far from the only one facing a Government that only days earlier had promised an end to top-down reorganisations. Sir Ara's report Healthcare for London, published last week, outlines a radical 10-year shake-up of healthcare provision in London.

Many predict it will become a blueprint for the Government's plans for the wider NHS.Sir Ara's proposals, including plans for a network of so-called polyclinics encompassing most GP practices and up to 50% of outpatient care, along with a concentration of acute and specialist hospital care, is by any standards a huge reform.

The plans have caused controversy, with the BMA warning they will 'destabilise and fragment' existing services. Londonwide LMCs warned if most GPs were moved to polyclinics it would 'destroy the very bedrock of British general practice'. Even organisations such as the NHS Alliance and National Association of Primary Care, often keen to embrace change, have spoken out against further upheaval.

But with some potential advantages for GPs, such as improved premises, what impact will the report really have in London and beyond?

Biggest change

The biggest single change for GPs will undoubtedly be the introduction of polyclinics.

The report proposes establishing a network of around 150 of them in London, each housing up to 25 GPs – initially from different practices, although the report suggests 'over time' practices may wish to merge.The polyclinics could be organised in a number of different ways.

Some GPs who contributed to the report back the federated, 'satellite' model, where one clinic provides services to a number of traditional practices. The report predicts 'polyclinics will become the site of most GP care' by 2017, although Sir Ara says the exact percentage is 'impossible to predict'.' To say I want 75% or 100% to be based in polyclinics is the wrong way round,' he says. 'That is a decision to be made on a local level.'

What is certain is that, if his vision works, alongside GPs there would be an unprecedented range of services, including outpatient clinics, consultant specialists, community services, urgent care and other healthcare professionals such as dentists and pharmacists.Immediate access to diagnostics such as point-of-care pathology and radiology will be particularly welcome for GPs.

Less welcome, perhaps, will be the extended opening hours. Not only will polyclinics provide urgent care for 18 to 24 hours a day, they will also be expected to offer evening GP appointments – perhaps as late as 10pm – and at weekends.Improved access has already been established as a cornerstone of Gordon Brown's fledgling health policy, but GPs have doubts, not only on their own behalf – having established clear working hours in the 2004 contract – but for the health service as a whole.

'It depends on whether the Government is willing to make the necessary resources available,' says Dr Tony Stanton, joint chief executive of Londonwide LMCs. 'On a personal level, I question whether that is a reasonable objective anyway. Does the NHS have the money available to make evening and weekend appointments a high priority for ordinary routine care?'

One particular concern about polyclinics, with patient lists topping 50,000, is the potential loss of the doctor-patient relationship, with some GPs fearing the advent of impersonal, 'taxi-rank' medicine. Dr Jeremy Harris, a GP in New Malden, south-west London, and chair of Kingston and Richmond LMC, used to work in a 2,000ft2 surgery, and now practices in an 11,000sq ft building.

'There are patients who have not liked our all-singing, all-dancing practice with a pharmacy, and feel it isn't as welcoming or as friendly,' he says. 'Yet many people have found it more efficient and cleaner – more what they would expect from a modern health service.'

However, Dr Cornel Fleming, a GP in Islington fighting a running battle with his PCT to remain a small practice, says polyclinics would ruin GPs' relationship with patients. 'I have 3,000 patients and I know every one of them,' he says. Sir Ara insists GPs will 'absolutely not' be 'forced' into polyclinics, and supporters of the plan argue the promise of better premises and support services will be a big incentive.

Model might change

But the report also acknowledges 'the transition will not be simple or without challenge from independent contractors', and warns 'traditional models of ownership, control and succession planning for their practices will need to be modified at least in part if the polyclinics are to be successfully implemented'.

Practices could be owned and run by private companies or foundation trusts, and salaried GPs are likely to play an increasingly important role, particularly in covering extended opening hours.

Sir Ara should be careful to heed the lessons from previous 'supersurgery' projects, says Dr Tony Rimmer, a GP and LMC member in Warrington. Two months ago, Warrington PCT was forced to back down after more than 21,000 patients signed a petition against plans to merge all its GPs into five giant APMS practices.

'There was a genuine patient outcry,' he says. 'It was very much that they didn't want to see the loss of individual practice identities.'

Sir Ara insists it will be different in London, with clinical engagement the key. But he warns even though he is now heading a national review of the NHS, also with a 10-year remit, what is right for London may not be the solution elsewhere. Still, there seems little doubt that changes to how GPs across the country do business are on the way once again.

As the Healthcare for London press launch draws to a close, Sir Ara looks more than a little relieved and turns to his press officer to ask: 'Is that the last question?' You can bet there will plenty more in the weeks and months to come.

Dr Tony StantonDr Tony Stanton Dr Tony Stanton

Does the NHS have he money to make evening and weekend routine appointments a priority?

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