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What does the Darzi polyclinic vision mean for GPs?

This week sees the close of a consultation on Sir Ara Darzi's plans for a network of polyclinics. And it might be the blueprint for the future of general practice.

By Steve Nowottny

This week sees the close of a consultation on Sir Ara Darzi's plans for a network of polyclinics. And it might be the blueprint for the future of general practice.

The Healthcare for London proposals, fiercely debated since they were launched last summer, set out plans for a wholesale reorganisation of primary care. Their remit is in theory limited to London, but in practice the implications are far wider.

No changes are more controversial than those planned for general practice, with a bold plan over the next decade to move thousands of GPs into a network of around 150 polyclinics.

Each typical polyclinic is likely to house up to 25 GPs and serve a population of about 50,000. It will offer a wide range of additional services, including diagnostics, consultant specialists, community services and pharmacists. Open 18-24 hours a day, and with many likely to be run by the private sector, it's no exaggeration to say they represent a revolution in primary care.

And while this week's consultation concerns just the capital, GPs from Surrey to Skegness are paying close attention.

Last month health minister Lord Darzi – who before his elevation last June was the architect of the London plans – confirmed polyclinics were set to be built across the country. The polyclinic model has already attracted strong criticism from doctors and patients, so when facing the media, Lord Darzi was perhaps understandably nervous.

After telling BBC Breakfast News that although ‘most patients love their GP', a change was coming, he said: ‘We need to separate that fantastic relationship between a patient and a doctor.'

It was a slip of the tongue, of course, and the BBC later decided he had meant to say ‘support that fantastic relationship', before removing the comment from its website altogether. But his inadvertent remark went straight to the heart of many GPs' fears over what polyclinics will mean for the future of primary care.

Merged polyclinic model

Londonwide LMCs' response to the Healthcare for London consultation, drafted by Professor Roger Jones, professor of general practice at King's College London, and obtained exclusively by Pulse, includes a damning point-by-point deconstruction of the polyclinic concept. It puts the future of the doctor-patient relationship at the top of its list of concerns, warning: ‘A merged polyclinic model seriously threatens this key aspect of general practice.'

Dr Anouska Hari, vice-chair of Westminster LMC, knows first-hand how important continuity of care is to patients. As a sessional GP working mainly in Kensington and Chelsea, she's used to seeing disappointment on the faces of those who can't see ‘their' doctor.

‘I hear it from the patients who say: "Very lovely to meet you, but I've now go to explain my whole history to you again",' she says. ‘Patients – especially older patients – get quite attached to seeing the same doctor.'

Patients themselves agree. Helen Bates, an underwriting technician from Worcester who has been battling mental health problems for 10 years, is so concerned about the changes she has launched an independent campaign – Save Our Surgeries – backing the traditional model of general practice.

‘A polyclinic is no good for a person with a chronic illness,' she argues. ‘My GP knows me inside out. For me to lose that is unthinkable.'

There are, of course, different models of polyclinics. A looser model – variously described as ‘networked', ‘federated' or ‘hub-and-spoke' - would see many of the services envisaged for polyclinics distributed among a cluster of existing practices.

This model has won far greater support among the medical profession, and indeed was mooted by the RCGP as part of the future of general practice. But the Londonwide LMCs report warns ‘we have a strong impression some PCTs are concentrating solely on the merger model'.

This model, they argue, is beset by problems. Patients will have to travel further to a smaller number of surgeries. Greater access to diagnostics – though one aspect of polyclinics widely welcomed by GPs – could prove expensive and lead to overuse of investigations.

But one of the biggest criticisms of the Healthcare for London project has been the consultation itself, branded a ‘sham' by GP leaders almost as soon as it was launched.

There's no doubt the sheer size of the consultation – which has cost more than £1 million – has been impressive. Forty roadshows have been held in public venues across the capital. Prior to the report's launch, 7,000 members of the public were polled by telephone, and well over 2,000 responses have been received since.

But the problem, critics argue, is that the outcome of the consultation has already been decided. In January, Pulse revealed that with the consultation still ongoing, a team of policy and clinical advisers had already been appointed to thrash out the details of how polyclinics will actually work.

Polyclinic sites identified

PCTs, meanwhile, are already eyeing up potential sites for the 10 pilot polyclinics expected to be operational by April 2009. Likely sites already identified include University College Hospital, the Royal Free Hospital and St Charles Hospital in Kensington and Chelsea.

Don Neame, Healthcare for London's director of communications and the man charged with masterminding the consultation, strongly denies PCTs are jumping the gun. ‘We always said it would be subject to consultation,' he says. ‘What we've said is that polyclinics, in whatever guise they are, need to be appropriate to the local population.'

But Dr Stephen Amiel, chair of Camden and Islington LMC, claims Camden PCT has already decided it will need a total of five polyclinics, including one at UCH and one at the Royal Free. ‘Having been the victims of a number of consultations in the past, we're all a bit sceptical of the impact they have,' he says. ‘We run the risk in Camden of potentially having 40% of the population having to see their GP in a hospital.'

Liberal Democrat MP Sandra Gidley last week attacked Lord Darzi's comments on the wider rollout of polyclinics, arguing he should have waited until the summer, when the final report of his NHS Next Stage Review will be published. ‘It seems odd to have a review, which is then pre-empted by an announcement,' she said.

Part of the problem is that after polyclinics were first unveiled in the Healthcare for London report, PCTs across the country rushed to slap a polyclinic label on almost any new health centre which vaguely fitted the bill.

Newcastle-upon-Tyne, Suffolk, Leeds, East Lancashire, Sheffield and South East Essex were just some of the areas claiming to have or be planning a polyclinic.

But while not all fully fit the model envisaged by Lord Darzi, there's no doubt there's also a genuine trend towards greater integration of primary care services.

'Not a polyclinic'

This week saw the official opening of Syston Health Centre, a brand new health centre in Leicester.

Dr Phil Green, one of the GPs behind the four-year project, insists while the centre was originally described as a polyclinic, ‘we don't want to be associated with the Darzi interpretation.'

The Syston Health Centre doesn't currently offer extended hours, and many of the extra services in the building will be accessed by patients across Leicestershire. But other similarities to the London model are striking.

The £6 million building will house two GP practices, a Boots pharmacy, echocardiography, ultrasound scanning, physiotherapy and a hand clinic. It boasts 31 consulting rooms and seven operating rooms, along with an 88-space car park.

The waiting area offers plasma screens, piped music - and ‘a cascading water feature'.

Unsurprisingly, patients love the new building, while GPs appreciate the extra space and instant access to secondary care services.

Ironically, while the BMA has warned of the dangers of imposing a ‘London-centric' model of healthcare on the rest of the UK population, many GPs in London believe polyclinics could actually be better suited to a semi-rural environment.

‘The model seems to lend itself to that sort of situation – and not to the densely populated inner cities,' argues Dr Stewart Kay, chair of Southwark LMC, who believes secondary care services could be of value in an environment where access to key diagnostics is at a premium.

But for Dr Charles Alessi, a GP in Kingston, and a contributor to the original Healthcare for London report, the whole polyclinic project is at a crossroads – and everything depends on whether PCTs plump for the merged or federated model.

‘I think we have an enormous opportunity in London, to ensure we have larger practices with the ability to deliver services at a depth greater than is available at the moment within primary care,' he says.

‘But I think the whole process really needs quite careful handling. Because we're in danger of the whole polyclinic idea being hijacked by the thought of PCTs shepherding people into a building against their will.'

All eyes on the plans for London

7 March 2008 – Healthcare for London consultation closes

6 May 2008 – Ipsos Mori and Joint Overview and Scrutiny committee present Healthcare for London consultation results

Mid-May 2008 – London PCT boards meet in public to discuss recommendations

12 June 2008 – Joint Committee of PCTs meets in public to discuss Healthcare for London recommendations and plan local consultations

Summer 2008 – Lord Darzi publishes final report of his NHS Next Stage Review into healthcare across England

Late 2008 – PCTs in London consult on local proposals

April 2009 – first ten polyclinic pilots in London due to be up and running

Patients – especially older patients – get quite attached to seeing the same doctor. Dr Anouska Hari, Vice Chair of Westminster LMC premises

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