A memorable image towards the end of the programme is of Gerry Robinson talking to the Chief Executive (CE) of the Primary Care Trust (PCT). They are at the site of a new £12million polyclinic development, two miles from the hospital in Rotherham at the heart of Robinson's challenge. Gerry expresses the view that this is a new government initiative that will be in direct competition with the hospital.
Polyclinics are, however, not a new idea. They were first described in 1920, but the vision of the comprehensive centre offering a wide range of primary care services to a local population has been resurrected by Lord Darzi in his 2007 NHS Review.
He recommends investment for Primary Care Trusts to enable development of 150 GP-led health centres in easily accessible places, open to all, and providing a range of services, including walk-in centres. The rationale for the increase in this type of provision is to ensure that people can access GP services between 8am and 8pm seven days a week; they will reflect the needs of the local population and will make optimum use of other nearby services, such as pharmacy and social care.
However, there have been walk-in-centres in our towns and cities since 2000. These were intended to improve access to high quality health care in a manner that is both efficient and supportive of other NHS providers. They open 7am to 10pm every day of the week, in convenient locations. No appointment is necessary and the provision covers information and treatment for minor conditions, health promotion, and referral to other services.
The vision of the modern day polyclinic includes such walk-in-centres. In several parts of the country walk-in centres are linked to accident and emergency departments of district general hospitals (DGHs). In these cases, people who need it can be redirected to secondary or emergency care making it a truly one-stop shop. Expensive facilities can be shared making best use of finite resources.
However, in Rotherham the centre is to be developed two miles from the DGH and Gerry Robinson sees this as a duplication of provision impacting adversely on the hospital. Gerry keeps going back to this point, asking whether the facility could be provided at the DGH at a fraction of the cost?
We know that central policy espouses increased patient choice and contestability (the playing-off of one service provider against others), so is the Rotherham polyclinic development driven by ideology rather than locally determined need?
Gerry asked the PCT’s Chief Executive about this, and suggested that the walk-in centre might be for people who feel unwell but cannot get to their GP immediately. The CE agreed that walk-in centres were intended to maximise the role of nurses.
But nurses running the centres are highly trained and experienced. Although there are differing models of training and education, they are will usually have been educated to a Masters level.
These advanced nurse practitioners are supported by other trained nurses and health care workers. Nurse practitioners have autonomy for the management of a total episode of patient care and are trained to:
- See patients with undifferentiated and undiagnosed problems as the first point of contact;
- Make a health assessment using advanced skills;
- Develop a plan of nursing care to promote health;
- Provide counselling and health education;
- Screen individuals for early signs of illness and risk factors;
- Have the authority to refer patients to other health professionals and services;
- Admit or discharge patients form their care as appropriate
Walk-in centres run by nurses, therefore, are certainly not intended to serve the needs of people who are just feeling “iffy”.
There is a concern noted by Gerry that nobody seems to know exactly what the Rotherham facility is going to provide, or how will it work. Gerry says that he is muddled about what is happening and would welcome a plan, a steer about where the NHS is going. Although there has been an NHS plan since 2000, another interim plan has been announced in 2007. So it’s perhaps not surprising that there seems to be a muddle.
What is clear though is that there is patchy provision of out of hours services across the country and that consumers want extended access to GP services. There are excellent models around and the aim is to bring the worst provision up to the standard of the best.
What is not helpful is to impose a top-down model of primary care services and to expect one size to fit all. Lord Darzi’s concept of the polyclinic should therefore be seen as one way, but not the only way, of providing flexible, accessible and comprehensive primary care to the local population.