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Here in England we are confused. Well, to tell the truth, I am confused, but so far none of my colleagues have been able to dispel the fog. Our patients are being persuaded that policlinics are the answer to the current problems of primary care, but despite paying the closest attention, I remain unclear what these institutions are supposed to be, who is supposed to be working in them, how they will fit in with the local health economy, and above all why and how such new centres are going to improve matters. As always when the central NHS organisation has come to some conclusion about the next development that is going to save us all there doesn't seem to be a serious attempt to test its ideas, in order to inform decision making with real evidence. The notion of having GPs working under the same roof as specialists is superficially attractive, although some of us fear that primary care doctors will lose confidence in their judgements, and be too influenced by doctors with a specialist agenda (the keenness of some hospital trusts to set up a polyclinic on their own doorstep, apparently to guarantee a supply of income-bearing patients would support such a view, quite apart from being an atavistic reminder of Victorian voluntary hospitals and their outpatient departments). Besides, we have published a paper showing that having specialists working peripherally is welcomed by patients but costs more. Or are we talking about buildings with large numbers of primary care services? If so, would it help to think of them as health centres? Those of us with long-enough memories remember that health centres were the ‘big thing’ in the 1970s and for a while did succeed in improving investment in buildings, and bringing services under one roof. Only the government changed; health centres became an embarrassment to government agencies now seeing themselves as commissioners and not providers. Some successful practices outgrew their health centres and had to move out; the buildings were often neglected or sold off. There are two obvious answers to such small minded objections: first that this time it won't be tired, wasteful, idle public sector that runs these buildings, but the sleek, efficient private sector. Which may be correct, but my own experience (mostly from a distance) of the private sector would lead me to suspend judgement for the moment. Second, nobody would pretend that the fabric of the buildings from which primary care currently operates is uniformly excellent. Paul Hodgkin has argued repeatedly in these pages that primary care in the UK has suffered from years of under-investment, and this is most apparent in the premises.
The paper on page 465 shows what can be done. A group in Bristol have presented their own development of new premises as a case study. Everything seemed to improve with the move: the doctors were more proud of their work, patients felt more relaxed and (perhaps as a result), communication was better. The patients especially welcomed the improvement in the reception area. The editorial on page 460 points out that their findings are consistent with a larger body of evidence, but also reminds readers that some improvements can be made at much less cost, and that such improvements should be considered as an investment, rather than as non-recoverable costs. On page 511 Mike Fitzpatrick presents his own experience as the other side of this coin: working out of an old health centre that's suffered from years of neglect. But then, as Graham Watt reminds us in his leader on the NHS at 60, the NHS has never made a serious, sustained attempt to confront the abiding inequalities (page 459). Another consideration as these new health supermarkets appear, is the effect of concentration on the periphery. A study of Devon's out-of-hours services on page 471 found that the call rates diminished as the distance from the centre increased, as well as with increasing deprivation. The policy makers running the NHS, rightly concerned about access, should bear this in mind as they plan further centralisation.
But perhaps as clinicians we cannot hope to agree with planners. That's certainly the view of the essay on page 512, where Charlotte Williamson looks at the different interest groups. She is especially gloomy at the patients' interests, that she feels are too often repressed.