The report draws on original research into facilities similar to the polyclinic models developed both in the UK and abroad. The proposals, which have been discussed as part of Lord Darzi’s NHS Next Stage Review, could bring together family doctors and specialists alongside other services, such as diagnostic testing, minor surgery, blood tests and X-rays.
The term polyclinic has been used to describe a variety of different approaches from very large super surgeries, which involve closing current GP practices and moving their services into the new unit, to the so-called hub-and-spoke model where most existing practices continue but share access to a set of new services in one facility. The King’s Fund report concentrates on the ‘big building’ model and examines the impact they would have on patient care.
It welcomes the government’s ambition to develop more patient focused and integrated models of care but warns that poor implementation of this model could create significant risks for patient care. Its key findings are:
Quality of care – polyclinics could help to redesign services around the needs of patients and deliver integrated care, particularly for people with long term conditions. However, the evidence suggests that in practice these opportunities are often lost – bringing together multiple services does not always result in better working practices between professionals, and there is no evidence that larger GP practices deliver higher quality care than smaller ones although they may be able to offer a wider range of services.
Accessibility of services – for some patients access to diagnostic and other services would improve and the impact would vary depending on how large and centralised the polyclinic would be. However, a major centralisation of GP services into polyclinics would make it more difficult for patients to visit their GP, especially those living in rural areas. This would be a major sacrifice given that primary care visits account for 90 per cent of all patient contact with the NHS, and that patients are less prepared to travel further to see their family doctor than they are to use outpatient and hospital services.
Costs – while there is a strong case for providing more support in the community to prevent hospital admission there is substantial evidence that shifting some specialist services out of hospital can prove more expensive. In these cases services can be less efficient and often fail to reduce demand on hospitals, so that the costs of new services supplement rather than substitute for hospital costs.
Workforce – the successful examples of integrated care delivered in polyclinics abroad may not transfer easily to the NHS in England due to important differences in the medical workforce. Here most specialists are based in hospitals not the community as they often are abroad. The European Working Time Directive and changes to postgraduate medical training will place further demands on specialists’ time. Some of the polyclinic models of care therefore present significant workforce challenges.
Report co-author Candace Imison said: ‘There is a strong case for challenging the way we organise health care in England. For some health communities the development of polyclinic-type facilities could offer great opportunities to establish more integrated care that delivers real benefits to patients. But these benefits will only be realised if the focus is on changing the way we deliver care, not just changing where care is delivered.’
King’s Fund Chief Executive Niall Dickson added: ‘Our model of health care has changed little since the NHS began 60 years ago – advances in technology, changes in the composition and working hours of staff, as well as patient expectations and evidence about what is effective, all signal the need to review how and where care is delivered. The polyclinic approach could be one way to redesign services around the needs of patients but we must not underestimate the amount of time, energy, and resources that would be needed to make it work.
‘We welcome the government’s assurance that there will be no national blueprint but that needs to be spelt out in unequivocal terms. Above all we appeal to ministers to make it abundantly clear that there will be no compulsion on local NHS organisations to erect buildings or follow this or any other centrally dictated model of care. Polyclinics may be the right answer in some areas, they will not be right for others. That should be a matter to be decided locally on a case-by-case basis using the best clinical evidence available together with a full assessment of the costs and the impact on patient access.’
The report’s analysis of polyclinics suggests that local planners should be careful to assess the benefits and costs of the polyclinic approach. Its recommendations aim to provide guidance for local NHS services and commissioners on realising the opportunities and avoiding the risks of introducing these new models of care:
Primary care trusts (PCTs) should proceed with polyclinics only where benefits to local communities in terms of quality, access and costs are clear. The primary focus should be on developing new care pathways, using technologies to improve patient care and better joint working across teams and professions. Developing new facilities may form a part of the strategy, but buildings should be a means to an end, not an end in themselves.
PCTs should consider alternative polyclinic models which do not require mass centralisation of family doctor services, such as the hub-and-spoke or federated model where most GPs remain in their premises and draw on resources in a central polyclinic or resource centre.
Strong clinical and managerial leadership supported by clear governance structures will be necessary. Polyclinics will also require workforce planners at the national and local level to explore and address the workforce implications as a matter of priority.