“Polyclinics” (Call Them What You Will) are Back

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Family practitioners in the UK have doubts about parts of the latest plans for reform within the National Health Service (NHS). In 2007, the government invited a health minister (a surgeon, Lord Darzi) to look at health care delivery as the NHS approached its 60th anniversary. His proposals1 include plans for more than 150 “polyclinics,” though this term was used only for those proposed for London. These need not necessarily be sited in cities or other urban areas but the dictates of geography and population density make that likely. For a clinic to be set up to offer more than just the services of a general practitioner is by itself of no great interest because many health centers already do that to some extent. However, the polyclinics would be on a much larger scale, offering access to some diagnostic and therapeutic services usually provided by hospitals besides more community-oriented services such as foot care, pharmacy, and rehabilitation—and doing so for 12 h a day, 7 days a week, and ideally under one roof. This is medicine’s answer to one-stop, nonstop shopping. Polyclinics have been tried elsewhere and the Darzi report takes account of experience in other countries. Confusion could probably have been avoided if the term itself had been ignored. Fairly or not, “polyclinic” is associated with Soviet bloc countries at their worst. Indeed (and ironically), the collapse of the Soviet Union was followed by a decision to replace its polyclinics by a more UK style of general practice even though it is not clear that the old arrangements were all that ineffective.2 In the former East Germany too, polyclinics were abandoned, only to return in reunited Germany in another guise, the Polikum, in 2005.3 This German development has attracted outside interest. So much so in fact that the Polikum in Berlin now has a business link with a British company to ensure that the many visitors do not disrupt its medical services.4 Cuba has polyclinics too and models can even be found in the US (e.g., the Westchester Medical Group in New York State5). The “polyclinics” of yesterday’s Moscow, today’s Berlin, Havana, or Westchester, and tomorrow’s London are clearly very different things, not least because of the differing ways in which services are funded. No country is going to be able to borrow a complete package from another. Although impressed by some features of the innovations in Germany, the UK’s Family Doctor Association deemed the German model “not suitable for complete replication in the UK NHS.”4 The British Medical Association (BMA) is not the only critic of the plan in whole or in part6,7 but it is one of the most outspoken8 and earlier this year organized a 1.2 million signature protest. But then UK citizens have always been very loyal to the NHS and also, at its primary care level, to the notion of having a personal physician. However, getting access to a named general practitioner at a time convenient to the patient has long been difficult (and outside usual working hours and at weekends almost impossible). Anyway, polyclinics do not mean the end of general practice as patients (and the BMA) know it because at present only one of these novel set-ups is envisaged for each of the NHS primary care trusts and familiar general practices would survive alongside the new. Too megalithic, some critics say but we could have virtual polyclinics with federations of general practitioners. The Westchester group is not on a single site. UK urban clinics would be unlikely to match the “cleanliness, tidiness, and order demonstrated in the Polikum clinic,” concluded one group of visitors.4 So, enforce higher standards. Whether there will be the financial provision to ensure that all polyclinics are top quality (as in the navy, NHS flagships are well endowed) is a more valid cause for concern. Clearly, primary care in the UK is going to change, and it should. However, politicians like to leave something to be remembered by before they leave office or are voted out. They are never in post long enough to allow experiments (and polyclinic-like arrangements are already under observation in cities such as London and Belfast) to run their natural course and be fully evaluated before policy becomes written in stone. In opposing what it sees as the current “headlong rush” into these new health centers, the BMA has a point.