06 June 2008
Polyclinics are trumpeted as the best way to revolutionise patient care in the UK — but bringing together the various services will work only if they are properly integrated, warn Candace Imison and Chris Naylor
The coming month will represent 'the end of the beginning' for the next stage of NHS reforms, according to Lord Darzi, the eminent surgeon turned health minister. The final report of his Next stage review will lay out the government's vision for the NHS as it enters its seventh decade, and could have profound implications for how services are delivered. Accompanying reports from each of the regional strategic health authorities will outline the ambitions for each area of England.
One of the most high-profile elements of Darzi's work to date has been his proposals for a new generation of community-based facilities in which general practitioners are located alongside specialists and community care professionals, These have been referred to variously as polyclinics, super-surgeries or health centres.
The hope is that the polyclinic model could overcome several longstanding problems with NHS services. By housing GPs and other professionals under one roof, divisions between primary care and hospitals could be closed, enabling services to become better integrated and more patient-focused. It is also hoped that by allowing services to be shifted out of hospitals into facilities closer to people's homes, polyclinics will make specialist care more accessible for patients and less costly for the taxpayer.
Darzi has sought to allay concerns that polyclinics would be imposed on local health services by publishing a recent report, Leading local change. This insisted that any change would be locally led and undertaken in consultation with patients, carers and members of the public.
In his 2007 review for London's NHS, Healthcare for London, Darzi proposed that polyclinics should become the main sites for Londoners' health care, with most GPs in the capital closing their own surgeries to move into these larger centres. The centres would contain around 25 GPs, along with diagnostic equipment and a range of other services such as outpatient care, pharmacy and optometry.
The review drew on international examples of polyclinics, such as the Polikum, at Friednau in Berlin, and the Westchester Medical Group in New York. Both clinics provide rapid access to high-quality care from multi-disciplinary teams of specialists and GPs. Both have exploited new technologies to deliver more patient-focused and integrated care, and have high levels of patient and staff satisfaction.
While it has not been claimed that the model described in Healthcare for London would be suitable for the rest of the country, the interim report from the Next stage review has laid out plans for 150 new 'GP-led health centres', providing a similar range of services.
The King's Fund has conducted extensive research to identify the implications for patients and staff, both positive and negative, of these sorts of models. Our research assessed the possible impact of polyclinics on the quality, accessibility and cost of health services. We have drawn on published information and original research into facilities similar to the polyclinic model in the UK and abroad. In particular, we have examined facilities built in England using the NHS Local Improvement Finance Trust (Lift), a procurement route supported by public-private partnerships. Our conclusion is that while there are opportunities to improve the quality of care and address some longstanding problems in the English health care system, there are also risks, particularly regarding the transition to this new model.
In terms of quality, locating multiple services together in the same building presents opportunities for delivering more integrated care. But our research suggests that in practice these are often lost. In the Lift schemes we examined, the extent of joint working across different teams has generally been limited. The GPs remain as independent contractors, community staff are accountable to distant managers and specialists are firmly rooted in their host hospitals. Despite bringing professionals together under one roof in high-quality facilities, the absence of clear local leadership and integrated managerial structures means that established service structures and pathways – with all their faults – have simply been replicated within new buildings, and the goal of integrated care remains elusive. Co-locating services will not alone be sufficient to overcome existing barriers and develop new ways of working.
There are also grounds for caution regarding the clinical quality of specialist services moved into community settings. While existing research indicates that in some specialities – such as dermatology – quality is comparable to that of hospital-based services, the range of specialities for which evidence exists is relatively limited.
There is also a small number of cases in which the quality of care offered in primary care settings has been found to be inferior to hospital-based equivalents. If certain specialist services are to be increasingly provided in non-hospital settings such as polyclinics, systems of clinical governance and quality regulation will need to be adjusted to ensure that all health care meets certain minimum quality standards, irrespective of the setting in which it is delivered.
Research to date does not indicate that the quality of primary care services would be improved by a major concentration of GPs into co-located polyclinics. Although there is some evidence to suggest that some small practices might benefit from additional resources and logistical support, there is no simple relationship between practice size and quality, and no evidence regarding the very large practices implied by proposals for polyclinics.
Polyclinics present both advantages and disadvantages in terms of accessibility of services. If introducing polyclinics involved a substantial centralisation of primary care, the consequent reduction in access to such care would be a major sacrifice not adequately compensated for by the relatively smaller gains in access to specialist care.
Primary care visits account for 90% of all patient contact with the NHS. The population currently has very good access to primary care, with more than 80% of the population in urban areas living within 15 minutes of their GP, by foot or public transport. Evidence shows that as travel distances rise, patients are deterred from using primary care – but they are less influenced by distance when using outpatient services. This suggests that more accessible outpatient services would be a poor compensation for less accessible primary care.
The impact on the physical accessibility of specialist services is likely to vary according to geographical context and choice of location. Shifting services out of hospitals might be especially beneficial in rural areas, where currently two-thirds of households must travel for more than 30 minutes to reach a hospital using public transport. When shifting services into the community, there are also opportunities to target patient groups that need to use these services most frequently.
In terms of cost, both research and the experience of Lift schemes point towards important potential problems. The research shows that community-based provision can be more costly than existing hospital services – whether provided by GPs or consultants. Costs might prove to be additional to, rather than substituting for, the cost of existing hospital care, since several studies have found that provision of new community-based services do not reduce demand on equivalent hospital services.
There are also financial risks as a consequence of the current arrangements for payment by results and the national tariff. The national tariff can present the health economy with 'false' savings if primary care trusts ignore the impact on the acute trust of the withdrawal of activity. The transfer will drive up overall costs in the health economy unless two things happen. First, the removed activity must be re-provided at an actual cost less than that of the equivalent hospital based activity. Secondly, the hospital must be able to reduce its unit costs to ensure remaining activity is not provided at a loss. The findings from the Lift study confirm that this is a real risk, and already evident in some areas. Greater transparency in costs across the whole care pathway and refinements in the tariff to reflect case mix differences more accurately could mitigate these risks.
On the other hand, there is the potential for savings if relocation is accompanied by the redesign of care pathways, supported by changes in working practices and skill mix. The impact on the cost of managing long-term conditions will depend on the extent to which polyclinics succeed in encouraging collaboration between primary and secondary care, and multi-disciplinary team working.
Development of polyclinics on hospital sites might be one way to realise the benefits of more integrated care while avoiding the inefficiencies that arise when care is disaggregated. An important role for PCTs will be to ensure that a formal benefits realisation programme accompanies any new developments.
The polyclinic model therefore presents both opportunities and risks. Polyclinics have the potential to bring real benefits for patients – but if poorly implemented could inflate costs, fail to deliver quality improvements and threaten access to primary care. To avoid the risks, local commissioners in PCTs will need to focus first and foremost on developing new pathways and processes that integrate care for the patient.
Building new facilities might form part of the resulting strategy, but it will be insufficient to rely on co-location to drive the hoped-for improvements. And where new facilities are developed, strong clinical and managerial leadership – supported by clear governance structures – will be crucial. Polyclinics will also need strong commissioners to ensure they address local health needs and priorities and realise their full benefits in terms of cost, quality and access.
Most importantly, it is imperative that Darzi's Next stage review takes an enabling, rather than a prescriptive, approach. In this respect, Leading local change is encouraging, stressing that the final report 'will not be a grand plan or a national blueprint'. If this promise is borne out, and if the investment of time, energy and resources needed for planning and developing polyclinics is not underestimated, they will be more likely to deliver benefits for patients and staff.
Candace Imison is visiting senior policy fellow and Chris Naylor is health policy researcher at the King's Fund. The report, Under one roof: will polyclinics deliver integrated care?, was published on June 5
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