The King's Fund has scrutinised the dream of polyclinics and urges planners to be cautious.
Government policy is driving a fundamental shift of care from hospitals to more community-based settings. There is a growing expectation that this shift will be supported by the development of a network of new facilities in which primary, community and secondary care services are co-located.
A variety of names have been applied to these types of facilities. Lord Darzi's report on London called them polyclinics, while the subsequent interim report from the NHS next-stage review referred to GP-led health centres.
The terminology may have changed but the policy of developing facilities on this model continues to have considerable momentum, with primary care trusts being asked to begin planning 150 new health centres this financial year.
The King's Fund has conducted extensive research to identify the implications of the polyclinic model. In particular, we have looked at the experience of developing facilities similar to the polyclinics using the NHS local improvement finance trust. This highlighted some of the opportunities and pitfalls for PCTs if they seek to develop polyclinics locally.
The conclusion from our report, Under One Roof: will polyclinics deliver integrated care? is that while there are real opportunities to improve the quality of care and address some longstanding problems in the English healthcare system, there is a substantial risk of failing to realise this promise if the transition to this new model is not managed well. There are also particular risks to do with cost.
Here we look at some of the lessons from the research and the action we believe PCTs need to take to ensure any facilities developed on the polyclinic model deliver their potential benefits for patients and the broader health economy.
Delivering integrated care
The experience of the local improvement finance trust initiative suggests locating services together in one building will not be sufficient to overcome traditional barriers between staff groups. The schemes have generally been managed as facilities rather than as an integrated healthcare service. Once in the new buildings, GPs remain as independent contractors, community staff accountable to distant managers, specialists firmly rooted in their host hospitals. There is no clear managerial or strategic leadership. Little formal investment seems to have been made in supporting joint working.
To ensure polyclinics deliver more integrated care, considerable amounts of time, effort and resources need to be invested in their planning and development. Co-location alone will not be sufficient to generate co-working between different teams and professionals. There will need to be a strong focus on developing new patient pathways and ways of working, and exploiting the opportunities for joint working presented by new technologies. Investment in change management will be required, and responsibility for ongoing clinical and managerial leadership will need to be clearly identified.
It would be inappropriate to suggest a blueprint for services that should be provided in a polyclinic. Much of the merit of schemes of this scale is their capacity to adapt and respond to local circumstances. Commiss- -ioners should build the case for a facility based on the local need.
In our research, we found some common patterns in the types of services that had flourished in local improvement finance trust schemes. For example, providing direct access diagnostic services can hugely enhance the capacity of primary and community care staff to assess and treat a range of problems. Polyclinics also offer opportunities to foster multidisciplinary team working in the community, especially for those patient groups which need to access services most frequently. Good examples are the polyclinic acting as a 'community service hub' and base for teams supporting:
- integrated chronic disease management
- integrated older people's services
- integrated children's services
- integrated out-of-hours services.
In terms of general practice, commissioners could encounter difficulties in attracting practices to new facilities. A major centralisation of primary care is unlikely to be beneficial for patients, particularly in rural areas; hub-and-spoke or more federated models may be a better approach to pursue. Under this model the polyclinic would act as a central resource base for a co-ordinated network of practices.
The key for building is to design flexibility from the start. Many recognise services will need to change significantly over the life of their building. New building techniques enable flexibility to be built in. Walls, for example can be movable.
For best access, location is critical and polyclinics should ideally be developed in transport hubs. Local improvement schemes developed in sites with poor transport links have found this can offset the access gains hoped for by shifting services out of hospital.
Finding ways to integrate services more effectively within existing facilities or on existing sites would be preferable to developing a polyclinic in a less accessible location. Improved access by car cannot be assumed given local authority car parking restrictions on any new developments.
Polyclinics do offer opportunities to innovate and develop capacity in out-of-hospital care, but will require strong clinical and strategic leadership.
Our recommendations will help ensure success. You can download Under One Roof: will polyclinics deliver integrated care? free
- When planning, put services before buildings
- Build only where there is a demonstrable need
- Secure strong strategic and clinical leadership
- Invest in change and process management - to drive the more integrated care model
- Underpin developments with a full benefits realisation programme.
- Conceptualise as a community service hub of GPs and others
- Provide direct access diagnostics
- Focus on chronic diseases, high-volume activities and specialties.
- Design in flexibility
- Plan for transport accessibility
- Consider alternatives to a buildings-based solution, eg through exploiting IT and new technologies
- Ensure a strong clinical and managerial governance framework.