Focus on...rollout of Darzi plans

21 May 08

The receptionist sounded puzzled. ‘Darzi? What’s a Darzi then?’

For all the talk of bottom-up, clinician-led reform, it’s clear the NHS Next Stage Review has yet to reach the staff at least one small practice in East Anglia, as Pulse sought reaction to what has the makings of a massive primary care overhaul.

But it won’t stay that way for long. Over the past year health minister Lord Darzi has been touring the length and breadth of the country, drawing up a blueprint for a radically reshaped NHS. At the same time, every SHA outside London – which published its own Healthcare for London consultation last summer – has been drawing up local plans.

Now, the results are in. In a series of high-profile launches, SHAs last week began unveiling plans packed with radical proposals for primary care, including a further roll-out of polyclinics, a shake-up of out-of-hours care and plans to shift even more hospital services into the community.

Lord Darzi’s national report, expected among other things to herald the beginning of the end for the MPIG, will follow next month. By the end of the summer, it’s a safe bet every GP receptionist in England will know just what a Darzi is.

A dirty word

Perhaps unsurprisingly, the SHA reports published this week have largely downplayed the policy most closely associated with Lord Darzi. Ever since his Healthcare for London review proposed moving the capital’s GPs into a network of 150 giant health centres, the surgeon-turned-politician has been inextricably linked with the polyclinic model. Ever since, those involved in the Next Stage Review have been falling over themselves to insist that ‘one size does not fit all’.

NHS East of England, the first SHA to unveil its plans, pointedly failed to use the ‘p’ word once its 131-page launch document, and speaking at the launch event, Lord Darzi told Pulse the decision on establishing polyclinics should be made at a local level. ‘I haven’t heard the term polyclinic used here,’ he said.

But what about the polyclinic programme already under way, with every PCT in England required to commission a GP-led health centre by the end of the year?

‘What [the centres] should be is for local clinicians to decide,’ he said. ‘There is one in every PCT because it’s a democracy.’

Polyclinic, says Dr James Kingsland, chair of the National Association of Primary Care and a key primary care adviser to Lord Darzi, has become a dirty word in Government circles.

‘He’s lumbered now with explaining something he never said,’ says Dr Kingsland. ‘I can tell you one thing for certain – the word polyclinic will not feature anywhere in the Next Stage Review relating to primary and community strategy.’

But while NHS East of England failed to mention polyclinics at all, other areas have been less circumspect. NHS Yorkshire and the Humber’s report, released two days later, does use the word ‘p’ word. It suggests polyclinics could either be based in existing buildings – ‘LIFT schemes, large GP premises, community hospitals and local general hospitals’ – or could be ‘virtual’ or ‘networked’.

‘There is a great need for much closer integration between generalist and specialist clinicians,’ the report says. ‘This would be facilitated by working in the same building as envisaged in the polyclinic advocated by Lord Darzi’s NHS Review.’

NHS South West also calls for greater integration of primary care services, without mentioning polyclinics by name.

Dr Will Warin, a PEC chair in Bristol and one of the clinicians advising the NHS South West review, explains: ‘A polyclinic’s just a building – you need to have the infrastructure to deliver it.

‘But a division between primary and secondary care isn’t always helpful. There are lots of things that could sit in between. We’ve seen a lot of that with specialist diabetes care, specialist COPD care, where what used to be provided in hospital is now provided locally.’

Another key element of the first SHA plans is a planned shake-up of urgent care. In addition to creating a new single three-digit number for patients to access urgent care, possibly 888, all the reports backed the roll-out of ‘urgent care centres’.

A relatively new concept, these will be GP-led, and a gateway to emergency and urgent care – freeing up A&E departments to treat blue-light patients (NHS East of England predicts the centres could eventually take on 50% of A&E work).

But there is widespread confusion over where exactly urgent care centres will fit in with current out-of-hours provision. In Bristol, urgent care centres will dovetail with existing out-of-hours providers. But in Hertfordshire, where a network of eight urgent care centres is being developed, PCT managers see them as very separate from out-of-hours cover. The first centre, scheduled to open in October, will replace an A&E department at the non-acute Hemel Hempstead hospital.

Dr Richard Clapp, medical director of Cornwall’s out-of-hours provider Kernow Urgent Care Services, acknowledges in some areas they may help reduce A&E attendance. But he adds: ‘There is the potential for confusion as to where patients should access urgent care, as traditionally this has been through GP or out-of-hours services.'

Unclear for patients

Dr Peter Graves, chief executive of Bedfordshire and Hertfordshire LMC, agrees: ‘From a patient’s point of view it’s extremely unclear,’ he says. ‘My surgery is now supposedly going to be open until 8, a Darzi centre is going to be open 8 till 8, urgent care centres from whatever time they can afford and then there’s casualty. I’ve got a child with a temperature – where do I go?’

What’s striking is not just the individual proposals, but the sheer scale of the reviews: from maternity services to end-of-life care to hospital-acquired infections. While the exact aspirations vary from region to region, tough new targets in a series of clinical areas are proposed, notably in stroke care.

Given carte blanche to rethink the NHS, the eight clinical pathway groups in each SHA charged with leading the review also came up with some more unusual suggestions. In Yorkshire and Humber, for example, the review proposes making Choose and Book two-way, enabling hospital specialists to send discharge information and book patient appointments on generalist clinics, while there are also plans for an ‘NHS Club Card’, which would reward patients with healthy lifestyles with concessionary car park entry and points for health food purchases.

Dr Graves believes that, as ever, the devil will be in the detail. ‘We can’t criticise the plan itself - the aims are absolutely spot on,’ he says. ‘But I’m waiting to hear how general practice is going to be involved. In particular, things around access to general practice need resources and investment – and this has not been forthcoming.’

Crucial consultation

If much depends on how the reports are implemented, then the next 12 weeks – which sees the plans go out to public consultation – could be crucial. Ahead of the SHA reports, Lord Darzi publicly pledged changes to healthcare provision would only go ahead if backed by clinical evidence and local support.

But with plans for a compulsory polyclinic in every PCT already underway, GPs are remain sceptical. As BMA chair Dr Hamish Meldrum put it: ‘Public and healthcare staff have yet to see much evidence of these principles being delivered.’

And while the SHA reports released this week will shape the development of health services in their region, in many respects they are an appetiser for the main event, when Lord Darzi’s final report is published in late June or early July.

Dr Kingsland insists the final report will be ‘a good news day for general practice’ and that is ‘not a blueprint, not a diktat’. But in its own vision document published last week, the NHS Confederation repeated its call for the MPIG to be scrapped - and Lord Darzi is widely expected to settle the MPIG question once and for all.

One source close to the review is optimistic about its long-term impact on the NHS – but admits GPs are understandably apprehensive.

‘They’re very fearful about the future, they’re anxious about what the future holds,’ he says. ‘I don’t think people necessarily understand the depth of the fear actually.'