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Gatekeeper:
The Big Question: What are polyclinics, and why are doctors so angry about them?


The row over polyclinics reached a climax yesterday, with two separate developments


Why are we asking this now?

The row over polyclinics reached a climax yesterday, with two separate developments. While the British Medical Association stepped up the pressure on the Government by handing in a petition to No 10 against polyclinics signed by 1.2 million patients, a meeting of all 31 primary care trusts in London agreed to go ahead with plans for at least 150 polyclinics in the capital, as recommended in last year's report from the Health Minister Lord Ara Darzi. The Government also wants a network of "GP-led health centres" across the country.

Why are polyclinics such a hot potato?

Few would have predicted when Lord Darzi published his report a year ago that polyclinics would become a flashpoint between the Government, the profession and the Opposition. The BMA, having suffered one bloody nose at the hands of ministers last February over extended opening hours, resolved they were not going to suffer a second over polyclinics. They have mounted a successful "save our surgeries" campaign, claiming that ministers are bent on privatising general practice by bringing in commercial organisations. Ministers have responded by accusing the BMA of a "mendacious" campaign, deliberately misleading patients and spreading fear and despondency. The Tories say ministers' pledge that polyclinics will be in addition to existing GP services, rather than replacing them, will add £1.4bn to the NHS budget, over five times more than the £250m allocated.

What does this mean for the future of the NHS?

It looks bleak. Lord Darzi's review of the next stage of the NHS reforms is expected at the end of this month. From the beginning, he has stressed that progress depends on the involvement and co-operation of the medical profession and that the failure to recognise this has hampered progress in the past. Meanwhile, his fellow ministers and the BMA have been engaged in a slanging match the like of which has not been seen since Kenneth Clarke, the then Tory Health Secretary, accused BMA negotiators of "feeling for their wallets" 20 years ago. Relations between government and profession have reached a nadir.

What are polyclinics?

Not necessarily a single building – which has caused much confusion. The term may refer to a network of GP practices forming a "virtual" polyclinic. Essentially they are super-surgeries with up to 25 GPs, which will provide some hospital services such as X-rays, minor surgery and out-patient treatment. The simplest model involves several practices under one roof, sharing many services but operating as distinct practices with their own registers of patients (each of whom would have their own doctor). They would also offer consultations to patients not registered who walked in off the street, like existing NHS walk-in centres. A second, virtual model would involve a network of GP practices remaining in their own buildings but be linked to a local referral centre, which would provide diagnostic tests and outpatient clinics, either in a separate building or in one of the GP practices.

Why do the government and doctors disagree?

It is hard to say, because both sides keep shifting their ground. The BMA says polyclinics will mean patients have to travel further and undermine the personal relationship between patient and family doctor. Yet health centres containing a similar number of GPs have been part of the medical landscape for at least 30 years. The Government says polyclinics will be more convenient for patients, offering longer opening hours (8am to 8pm), and more services so they won't have to travel to hospital for tests and treatment. But despite ministerial denials of any diktat from the centre about their number, funding arrangements imply that every primary care trust must have at least one polyclinic or risk losing cash.

What is the case for polyclinics?

For decades, governments have talked about moving some care out of hospitals into the community, where it is more convenient for patients, reduces the burden on the hospitals and helps bridge the divide between primary and secondary care. None have succeeded, and staff numbers are growing faster in hospitals than in general practice, worsening the imbalance. Polyclinics are an attempt to solve this problem, and most experts welcome them as a suitable model for major cities, where hospitals are overwhelmed with minor cases and public transport is readily available.

What is the case against them?

A one-size-fits-all policy, which imposed polyclinics across the country, could do irreparable damage by driving out smaller local practices. They are not suitable for rural areas, where concentrating GPs in one place could create serious problems of access – though a virtual polyclinic might still work. A report by the Kings Fund last week, which examined the experience of other countries, found there was no evidence that polyclinics would improve care or save costs, even though they were able to provide a wider range of services.

What about the role of the private sector?

This is a crucial, unresolved issue. Primary Care Trusts will go out to tender for polyclinics, and commercial organisations such as United Health, Boots and BUPA will be able to bid against GPs for contracts to build and run them. The BMA says this is part of the Government's plan to "break" NHS general practice. Ministers say the private sector is essential to provide a competitive edge and to ensure services are geared to the needs of patients. Given the financial and management challenge involved in running a multi-million pound clinic with scores of staff, the dice may be weighted in favour of the biggest players. If that happens, commercial operators could focus on short-term contracts with a high turnover of staff and a loss of continuity of care for patients.

Who is to blame for this debacle?

The BMA bears a share of responsibility for its stubborn refusal to accept that there is anything wrong with general practice. While patients express themselves largely satisfied with what goes on in the consulting room, there is greater concern over what happens front of house – with access, appointments, and getting through on the phone. But ministers, too, must carry the can for failing to spell out their plans clearly and for ramping up the temperature of the debate with the profession. Now that polyclinics in London have got the go-ahead, a bout of bridge building is urgently needed between the two sides.

Will polyclinics be good for patients?

Yes...

*They will be more convenient for patients who need blood tests, investigations or outpatient treatment

*They will reduce the burden of routine work on busy inner-city hospitals, leaving them to concentrate on complex cases

*They will provide a boost to general practice, giving it more clout in the battle for resources with hospitals

No...

*Patients will have further to travel to receive a consultation and treatment from their GP

*Competition from polyclinics could draw patients away from local practices, forcing them to close

*Private commercial organisations will be better placed to bid for and run them, potentially undermining the NHS

Δ. Κουναλάκης:
Αυτή είναι μια επίκαιρη συζήτηση και στην Ελλάδα όσο δεν φαντάζεστε...
Έχω ήδη συναντήσει συναδέλφους που ασκούν ιδιωτικό επάγγελμα και συνασπίζονται ώστε να καλύπτουν όλο το 24ωρο ασθενείς ιδιαίτερα σε τουριστικές περιοχές και προσλαμβάνοντας και επιπλέον ιατρούς. Ενώ έχουν καθένας συμβάσεις με τα ίδια ταμεία συνεργάζονται με ίδρυση συνασπισμών που έχουν κοινή γραμματεία και λοιπό ιατρικό & παρα-ιατρικό προσωπικό και ταυτόχρονα διαπραγματεύονται καλύτερα και την παροχή υπηρεσιών προς ταμεία ή άλλους υποψήφιους πελάτες. Να μην πω τα παζάρια για το ποιον μικροβιολόγο θα επιλέξουν να μπει στην παρέα. Θα δείτε συστήματα τηλε-γνωμάτευσης ψηφιακών ακτινογραφιών και πολλά άλλα. Κάπως έτσι είναι και πολλά ιδιωτικά "ιατρικά κέντρα".

Αναζητώντας την ιθάκη στον ηλεκτρονικό ιατρικό φάκελο στην ΠΦΥ όταν αρχίσει να χρησιμοποιείται από περισσότερους από ένα ιατρούς, έπεσα και στον εξής σκόπελο: Η σχέση του ιατρού-ασθενή έχει ένα ποσό πληροφορίας που περιγράφει τις ιδιαιτερότητες του ασθενή από την οπτική γωνία του ιατρού. Αυτές ιδιαιτερότητες έχουν να κάνουν και με τον τρόπο που στέκεται ο ασθενής απέναντι στην ασθένεια, το πόνο, το σύμπτωμα, την ίδια τη ζωή, ενώ δεν υπολείπονται στοιχεία που έχουν να κάνουν με την "σπιρτάδα", την ευρηματικότητα & την υπομονή του ασθενή έναντι της ασθένειας. Αυτά τα χαρακτηριστικά, δεν ξέρω πως μπορούν να καταγράφονται τυποποιημένα, όταν ήδη τα στοιχεία του κλασσικού ιστορικού δεν έχουν τυποποιηθεί. Κι όμως επηρεάζουν και την σχέση του με τον ιατρό και την διάγνωση και θεραπεία σε επίπεδο ΠΦΥ.
Πως θα έχεις διαθέσιμη και καταγεγραμμένη αυτή την πληροφορία ώστε όλοι οι ιατροί να έχουν την ίδια πληροφορία για τον ασθενή που έχει ή απαιτεί πρόσβαση σε υπηρεσίες υγείας 8πμ-8μμ;;; Αν την καταγράψεις, μήπως είναι πιο δαπανηρό; Αν δεν την έχεις, μήπως πέφτει η ποιότητα; Τελικά, μήπως στο βωμό της "εξυπηρέτησης" του ασθενή, χάνεται η έννοια του προσωπικού σου ιατρού και ότι θετικά σημεία αυτή έχει;;;

Gatekeeper:

--- Παράθεση ---Στάλθηκε από: Δ. Κουναλάκης
Η σχέση του ιατρού-ασθενή έχει ένα ποσό πληροφορίας που περιγράφει τις ιδιαιτερότητες του ασθενή από την οπτική γωνία του ιατρού. Αυτές ιδιαιτερότητες έχουν να κάνουν και με τον τρόπο που στέκεται ο ασθενής απέναντι στην ασθένεια, το πόνο, το σύμπτωμα, την ίδια τη ζωή, ενώ δεν υπολείπονται στοιχεία που έχουν να κάνουν με την "σπιρτάδα", την ευρηματικότητα & την υπομονή του ασθενή έναντι της ασθένειας. Αυτά τα χαρακτηριστικά, δεν ξέρω πως μπορούν να καταγράφονται τυποποιημένα, όταν ήδη τα στοιχεία του κλασσικού ιστορικού δεν έχουν τυποποιηθεί. Κι όμως επηρεάζουν και την σχέση του με τον ιατρό και την διάγνωση και θεραπεία σε επίπεδο ΠΦΥ.

--- Τέλος παράθεσης ---

Polyclinics 'may damage GP trust'

Polyclinics may damage trust between the patient and GP, harming the quality of care in the process, experts say.

A Leicester University study quizzed 236 patients about continuity of care - seeing the same doctor on each visit.

The researchers found those who saw the same GP were more likely to trust them and keep to courses of medicine.

But the government denied the network of super clinics being set up in England would cause disruption to the GP-patient relationship.

Polyclinics are large health centres housing a range of health professionals such as GPs, nurses, physiotherapists and hospital doctors.


 Our overriding objective is to deliver the best possible service to patients
Department of Health spokesman 

NHS bosses have been told to set up 150 centres outside London, while a host of them are expected to be created in the capital.

They have been designed to relieve the pressure on hospitals by providing a whole range of basic care.

Doctors' leaders have been critical, saying they will put the traditional system of GP care under threat.

The researchers surveyed patients from three GP practices asking them to give marks for the trust they felt in the doctor they had seen during their last visit.

A total of 150 had seen their usual GP with the rest seeing a different one.

In-depth discussions were also carried out with 20 patients and 12 GPs.

Those seeing their usual GP gave them a trust rating of 83.5 out of 100, while those seeing a different one gave them 72.6.

Having good care in the past and the expectation that the GP would provide the follow-up care in the future were cited as the main reasons for the usual GP scoring highly.

Patient trust

Lead researcher Carolyn Tarrant said the findings had major implications for government policy as polyclinics and other large health centres were likely to have large numbers of GPs.


 If patient trust declines, then medical outcomes may be adversely affected
Carolyn Tarrant, lead researcher 

"The government is setting up numerous polyclinics, super-surgeries and walk-in centres all over the country.

"They are bound to reduce continuity of care and our research show that this may lead to a decline in patient trust.

"If patient trust declines, then medical outcomes may be adversely affected."

She said this could include failure to follow prescriptions or advice from doctors.

Dr Laurence Buckman, chairman of the BMA's GP Committee, said: "For someone with a chronic condition, a long-term relationship with a doctor they trust and who knows their history is vital."

But a Department of Health spokesman said the network of health centres was on top of existing GP services, not instead of them.

And he added: "Our overriding objective is to deliver the best possible service to patients.

"Patients repeatedly tell us that they want better access to GP services and want healthcare that is more personalised and convenient, so services need to adapt to respond to this need."

Story from BBC NEWS:
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Published: 2008/09/22 23:01:02 GMT

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