Will polyclinics benefit patients?
Where GPs agree to work in polyclinics, they can provide a wide variety of services to patients without losing the personal touch, argues Dr Charles Alessi. But Dr Max Levy’s patients wanted nothing to do with a planned polyclinic, and he believes the proposals threaten the principle of personalised care.
Where GPs agree to work in polyclinics, they can provide a wide variety of services to patients without losing the personal touch, argues Dr Charles Alessi. But Dr Max Levy's patients wanted nothing to do with a planned polyclinic, and he believes the proposals threaten the principle of personalised care.
The concept of the polyclinic has attracted mainly adverse publicity during the past few months.
The potential advantages of an increase in capacity and capability, particularly in urban environments, have largely been ignored because of the difficulties in understanding how a multitude of practices, with totally differing philosophies of care, can work together when corralled into a large impersonal building.
However, there are ways to realise all the advantages of the polyclinic model without the potential disadvantages.
I do not believe GPs should be coerced into moving into large, impersonal new buildings. There may be cases where practices, often in cramped and non-compliant buildings, will elect to move.
As long as this maintains the link with patients it is to be encouraged. There are advantages to having practices that are big enough to be able to offer tailored services to their population.
The concept of the one-stop shop is understood by everyone. But the large numbers of small practices in our urban environments, often with personal histories of practice dissolutions, may make such a model difficult to realise in the short term.
The challenge is delivering this without losing the personal service, identity and focus of a local community.
A new model of care
There is an alternative model which would suit cities better – the distributed polyclinic. General practice fosters communities.
This is particularly important in an urban sprawl where, because of the breakdown of traditional ties and large numbers of new residents, patients look to their local general practice as a focal point of their locality.
I work at the Churchill Medical Practice in Kingston on Thames, Surrey, in a large practice staffed by 11 doctors plus training grades and operating from our central site plus two satellites.
Kingston is not all leafy suburb. We serve a very mixed population with numerous discrete areas of deprivation.
Within these pockets, the patients who live there, often not English speakers, are surrounded by affluence.
We also have large numbers of older people – often living alone – who would suffer if we were to move to a more distant location. This population is one that particularly looks to the surgery as one of the local amenities, like the newspaper shop.
The most important difference between the Churchill distributed polyclinic model and the status quo is encapsulated in a single word, corporacy. We are a corporate organisation and follow a single set of guidelines to manage chronic disease.
We have tightly managed call and recall systems and depth in the delivery of health as we have the necessary size to enable us to employ our own specialist nurses in diabetes, respiratory disease and family planning and sexual health, who all follow our own evidence-based pathways of care.
Our satellite branches are staffed by groups of clinicians who rotate back to our central hub, maintaining the ethos of the practice and ensuring we all work in a similar way. We use the same single set of electronic notes wherever a patient is seen.
The public values its local NHS. It is a reference point in people's lives within the urban landscape and we can retain this as well as introduce the undoubted advantages of polyclinics.
As long as polyclinics bring upping of quality of service and improved adherence to evidence-based guidelines in larger corporate organisations, then I cannot see why we should not all support them.
Do we really espouse a model of care where patients need to go to the large impersonal and largely unreformed district general hospital to get basic management for their chronic long-term conditions? I believe our patients deserve better.
Supporting polyclinics does not mean we need to lose our sense of community and localism, and the Churchill model is a living, working example of what is possible and replicable.
Dr Charles Alessi is a GP in Kingston and medical director of the Kingston Co-operative Initiative
If polyclinics are the way forward for delivering primary care it will be reasonable to expect improved medical outcomes, delivered through personalised care, in an environment where access is equally available to all.
Unfortunately, the Darzi review, which recommended polyclinics, will have the opposite effect in many respects.
Currently primary care delivers a generally high standard of care at relatively low cost.
The majority of the public is happy with this, as the Government's patient survey showed. We all want better services, but where is the evidence polyclinics will deliver this?
Let me tell you my own story.
A PCT in a large provincial town launched a strategy to amalgamate 29 surgeries under its wing and herd GPs into five new buildings. It decided not to discuss any of this with 120 local GPs and told the public it knew best.
The PCT spokesperson told GPs 29 local surgeries simply didn't make sense.
‘Hang on,' someone said. ‘We all want to improve healthcare but what will you do about staffing these shiny buildings and how will you deliver continuity of care? Oh, and how much will they cost? And before you go – what do you know about primary care?'
So off went the PCT to ask Mr and Mrs Public what they thought. And this was where it got interesting. Mr and Mrs Public wanted to know more and kept asking the same questions over and over:
‘How can you guarantee I'll be able to see my own doctor in this enormous surgery?'
‘Why are you taking away my local practice?'
‘What evidence do you have for your model?'
‘Why didn't you speak to the local GPs about this beforehand?'
‘How will the elderly and chronically sick access their own GP when the latter becomes a shift worker?'
‘Do you know what continuity of care means?'
And that old chestnut: ‘Where are your costings?'
Mr and Mrs Public were not happy. They wrote lots of letters to newspapers and MPs.
They went to public meetings. They signed their names on a petition and their neighbours did too. Between them, they signed more than 20,000 times.
Eventually the man from the PCT called GPs into his office to tell them he could not take his plan any further because he had not been able to satisfy the public. Someone was overheard whispering about ‘patient choice'.
And from that day on it was decided to find local solutions to local issues. By all means look at different ways of helping Mr and Mrs Public. But don't destroy what they value and trust most.
What people value most is personalised, high-quality medical care with convenient local access. Continuity of care may seem unimportant when you are young and healthy but it does matter to the majority of NHS users – the old and the chronically sick.
Polyclinics, which will eventually be managed by private companies under APMS contracts, will unwittingly dismantle these foundation blocks of primary care, delivering conveyor-belt medicine through a nameless workforce, without a shred of evidence medical outcomes will improve.
Yes, we need to look at redistributing NHS funding to where it is needed most and providing some secondary care services in the community, where they will be more accessible.
But the idea it will be good for the public's health to amalgamate practices into an amorphous, centralised service is not based on evidence, nor is it what the public wants. Local solutions to local issues are what is required. Fortunately, a properly informed public will not be duped.
Dr Max Levy is a GP in Warrington and member of mid-Mersey LMC