Chronic polyphobia? Phil Gusack chaired the 2009 Architects for Health annual debate at the Reform Club on 5t February, and considers some of the arguments pro and con polyclinics.
When Gordon Brown appointed Lord Ara Darzi, the eminent Professor of Surgery at Imperial College, to be a Parliamentary Undersecretary of State at the Department of Health in July, 2007, it was hailed as a shrewd move. Who better to persuade Britain’s doctors to keep pace with the conveyor belt of NHS reforms and public health initiatives than another doctor? Instead, it led to non-stop wrangling and sensational chatter about ‘soviet-style’ policlinics, and 1.3 million signatures on a British Medical Association (BMA) petition to protest against polyclinics. In the face of such a threatening set-piece on the Westminster pitch, government players lined up in a defensive wall, disowning the P word with the credibility of a fallen Rinaldo. All this may suggest that the referee of public opinion is not on the government’s side, but history is. Boria v ambulatorii (Borja at the policlinic) S. Zak ; Ill.: Vl. Konashevich, Moskva: Gosizdat, 1928 Architects for Health 2009 Debate: This house believes that polyclinics will deliver higher quality care than traditional GP practices
Richard S Smith
Dr Brian Fisher
Proposer
Seconder
Mark Simmonds MP Opposer
If anyone was inspired by soviet policlinics, it was certainly not Lord Darzi. He is only 48. The BMA refusniks mean Lord Dawson, who proposed a national primary care system based on health centres in 1920. As his own patients included three Kings and he was twice president of the BMA, we can reasonably assume that the BMA media team knows it too. Any insinuation that the BMA is less committed to public health than (say) the Royal Institute of British Architects (RIBA) is to the environment is, obviously, unintended. Nevertheless anyone who has attended almost any of the Architects for Health (AfH) meetings over the last three years will appreciate that many hospital designers who have endured the sensory deprivations of Private Finance Initiatives secretly wish the RIBA had defended the business of its 40,000 architects with some of the gusto that the BMA brings to the defence of its 33,000 physicians.
John Lipetz Seconder
AfH kicks off its annual calendar of lectures, seminars and study tours with a formal debate at the Reform Club, the home of radical thinking on Pall Mall. It’s the one night of the year that AfH Cinderellas get to go to the ball. This year’s debate argued the pros and cons of polyclinics, and the conviction and eloquence of the speakers can be summarized
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by the Reform Club’s own description of their clubhouse: ‘‘having a chaste exterior and a richly flamboyant interior’. Like Sir Ebernezer Howard’s 1898 Garden City proposals, Lord Dawson’s schematic for primary care is a rational response to decades of unregulated boom. They are about hierarchical organization and spatial separation. Urban anoraks continue to pick at the differences between Welwyn Garden City and Hampstead Garden (Guardian) Suburb, just as healthcare historians point to the conceptual differences between two landmark health centres: Sir Owen Williams’ Pioneer Health Centre in Peckham (1935) and Berthold Lubetkin’s Finsbury Health Centre (1938). Today they remind us that nothing is futureproof. Pioneer survived the Second World War but not the launch of the NHS. It closed in 1950. Finsbury, on the other hand, is still in use, but only just. Primary Health Centres, The Dawson Report, 1920
Finsbury Health Centre
NHS Islington, the local primary care trust (PCT) appeared determined to close it because they say that its Grade 1 Listing makes it virtually impossible to upgrade. NHS London backed them and the Secretary of State backed NHS London. Since then, local protesters persuaded the Borough of Islington Health and Wellbeing Committee to reversed its initial support and refer it back to the Health Secretary, and he is expected to defer to the Independent Reconfiguration Panel (www.inpanel.org.uk). If the PCT gets its way, the Centre will be up for sale, although the chances of finding a buyer for this protected landmark in current market conditions must be slim. The good news: Starbucks buglers have sounded the retreat. The bad news: the Colonel plans bucket-loads of new shops. Such distasteful scenarios are pure speculation on my part but the question of how the Health Estate disposes of its assets has long been cloudy. The bigger question - what all this means to Islington patients – highlights the core issues that led Lord Darzi to prescribe polyclinics in the first place. Last year the Healthcare Commission’s survey of PCT performance and quality of service (weak, fair, good or excellent) rated Islington as only fair. Why? th On October 16 , 2008, Rachel Tyndall, NHS Islington’s Chief Executive said: ‘Islington is a challenging area in which to provide healthcare because of our incredibly diverse
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Tower Barnet Hamlets Population 364,000 232,000 GPs 244 139 People/GP 1,490 1,670 Table 1: Patients per GP
England London Barnet Islington Tower Hamlets
Q11 Did your GP listen carefully?
Q12 Did you have enough time?
Q15 Did your GP explain
% yes 83 78 78 75 71
% yes 76 69 71 66 61
% yes 74 70 72 71 65
Table 2: Extract from Healthcare Commission Survey 2008 Section 3: Seeing a doctor
population and high levels of deprivation and health needs.’ Is deprivation driven by diversity or a doctor deficit? The World Health Organization collects doctors per capita data. It is often cited along with percentage of GDP expenditure and life expectancy to show that the NHS delivers longer life for far less money than the US can and/or that although the doctor per capita ratio in Sweden is lower than in the UK, Swedes live longer. It’s all good stuff for preventionistas but no consolation when you or yours need a doctor after hours. My alternative rule of thumb is how much time your GP can spare you. When the NHS opened for business, around 16,000 GPs signed on to serve 40 million people in England. Today 33,000 GPs serve 50 million. Working 37.5 hours a week for 48 weeks and that every minute is a patient-contact minute, gave a 1948 patient 43 minutes a year. Today it is 69 minutes.
The GP’s key task is to diagnose. How long does that take? Whatever you estimate, it is in minutes. To perform their equivalent task - the analysis of a design problem (RIBA work stage A), architects and engineers take weeks. The designer-client relationship is a choreographed courtship, but GPs can only speed-date their patients. Table 1 shows the GP/patient ratios in Barnet and Tower Hamlets and table 2, shows the patient dissatisfaction.
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Data presented in Hansard (July 7 , 2008) shows the trend in the 1997-2007 period: 19% more GPs but 10% fewer practices. In 2004, 23% of GPs were working in group practices of ten or more, but an equal number worked single-handed. Almost half of GPs still work in converted homes or shops, older than the NHS, with substandard access, cramped conditions and no possibility of expansion. Today 8,260 practices to serve England’s 130,410 sq km. (A lot? The Church of England has 16,574 churches!). On paper, one practice with four GPs has to cover over 6,000 patients across 15.75 sq km. The important point is not the number itself but that the eradication of healthcare inequality – a New Labour core brand value – involves sharp geography and joined-up planning. If the Reconfiguration Panel does get involved in the future of Finsbury, its 16 distinguished
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members will bring a wide range of medical expertise and experience in patient representation, but in their ranks there are no geographers, town planners, surveyors, transport engineers, lawyers, property developers or, indeed, financial specialists. The real problem is not just what to do in Islington (or anywhere else) but where to do it and secondarily, how long to do it for.
Pharmacy in Assura’s Waters Green Medical Centre in Macclesfield
PCTs are supposed to work together with local planning departments. But there are three problems. First, planning departments concentrate on building control – approving or refusing planning consents. Pro-active planning is contracted out. Regime change proceeds at glacial speed. Second, after John Prescott stood down as deputy prime minister, Gordon Brown did not appoint a successor as planning supremo. Third, property developers have drained the best planning brains and skilled negotiators into the private sector. It means that whether or not the Health Secretary is too top-down, there is no top to join up with to link healthcare and land use planning.
Architects can give you all the anecdotal evidence you can absorb about young Australian apparatchiks dictating what can and cannot be done in conservation areas – an urban context in which they are newcomers. The problem is not, of course, their nationality or the skew of their life-work balance around test matches, but that planning departments are under-manned and stripped of the aptitude for negotiation. However sophisticated PCT teams are, they cannot do joined-up thinking unless there is someone to join up with.
Based on my own observations of street life around my own GP’s surgery, (a badly converted cramped semi-D on a quiet street in Barnet, a good 15-minute buggy-push from the nearest bus stop) hell breaks loose when local mums get back from the school run and find their spaces pinched by patients. Local councillors told me that for every one of the 4,500 Barnet residents who signed the BMA petition, far more will vote for any party who does something to solve this problem, and if polyclinics do that, well and good. The countervailing responses include (a) people wouldn’t need to see their GPs if they walked more and/or (b) carbon footprints threaten everyone’s health so encouraging traffic is
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morally reprehensible. How these arguments play out in our side streets remains to be seen but, whether a borough is relatively omfortably off or unquestionably deprived, the new realities of construction industry implosion simply deletes cash injections from Section 106 agreements from borough balance sheets.
Woodlands Medical Practice, Barnet
Health centres by any name may take the heat out of the side street, but their own parking requirements mean they are unwieldy pieces to patch into the dense urban fabric of our inner cities. Despite the fact that it is next to the bus station, the 40-GP supersurgery that recently opened in Macclesfield still has parking for 220 cars. Half are for GPs and staff. Since they negotiated a 22.5% pay rise and dumped night and weekend service back into the PCTs’ in-trays in 2004, are GPs going to take the bus? Do turkeys vote for Christmas?
Logistics led us out of the fields and into cities, out of cottages into mills, out of coffee shops into the Lloyds building, from inns to Holiday Inns and out of the grocer into the supermarket. Odious as it may be to put primary care and supermarkets in the same sentence, the comparison is relevant. Parking is one parameter. Lower prices, wider choices, late night opening, internet shopping and home delivery are others. Your PCT can’t get economies of scale from a single-handed GP and you can’t get wide choice, night or internet services from yours either. But if you live in Harrow, Hounslow, Lambeth, Redbridge or Waltham Forest, you soon can. These are the first five polyclinics, each with GPs, social care and community services under one roof. 26 more – one per London PCT – are to open in the next five years. They will, says NHS London Chief Executive Ruth Carnall, ‘tackle two of the biggest problems in the capital, namely patients finding it difficult to get a GP appointment and the result which is people turning up at A&E when they should be seeing their family doctor.’ BMA leaders counter claim that this threatens continuity of care, a lofty ideal that can only reliably apply to solo GPs, and then only daytimes on weekdays. Otherwise you’ll get a locum. Considering that BMA negotiators slid out of nights and weekends in 2004, their concern for continuity now is what we architects term a bit too postmodern. Besides which, the launch of Local Initiative Finance Trusts (LIFTs) in 2001 has, to date, led to 204 health centres open or on
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site and a further 33 schemes have received Treasury approval (financial closure), a capital investment of £1.8 billion, all without BMA uproar. So why the scaremongering about polyclinics? As the GPs’’ trade union, the BMA has always rallied its rank and file around the mantra of independent contractor status. The legacy of this is that around half of the national GP workforce is financially locked in to dysfunctional premises. Whether or not property-owning GPs want to get into polyclinics, the credit crunch means getting out of their semis in the side streets is now something they want to avoid at all costs. But as masters in the art of brinksmanship, BMA leaders must have figured that even though their members are not hedge-fund managers, they do take home an average of £118,000 a year – too much to risk losing the public’s affection by asking Gordon Brown for a bailout.
Professor Ara Darzi
Dr Hamish Meldrum Chairman of the BMA Bridlington polyclinician
What the BMA leadership campaign for and what its members want are often two different things. There is, for example, ongoing dissent on pay scales for younger doctors who feel the practice partners they work for are exploiting them. And there are many who are keen to work in polyclinics too, including no less a figure than BMA chairman Dr Hamish Meldrum. After a year of soviet style poliklinika disinformacja, Chairman Meldrum made more headlines – ‘I would deny charges rd of hypocrisy.’ (Guardian, 3 January, 2009) when it was revealed that he too was in a group of GP partners bidding for a contract worth £4.15 million to manage a polyclinic in Bridlington for five years. In the dug-outs of the Westminster pitch there was some gratification: Meldrum’s efforts to force Darzi offside had only led to an own goal! A few days later, however, the House of Commons Health Select Committee gave Darzi a yellow card. It reported that it was not convinced about a roll-out in all 152 PCTs in England: ‘’We were disappointed that neither the government nor witnesses representing doctors could tell us what criteria should be used ...and the ability of PCTs and strategic health authorities (SHAs) to manage effectively these changes is a genuine worry.’ This rebuke would not be so bad if the idea of polyclinics had come up 18 months ago and not, as the BMA has reminded us, 90 years ago. If the Select Committee wants evidence it only needs to look at the Healthcare Commission’s survey. As good as NHS
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primary care is, 15 million people in England simply could not get a GP appointment. Their GPs are not listening to them and, it seems, neither is the Select Committee.
....................................................... phil@gusack.com March, 2009
Goodness Gracious Me’ eSophia Loren and Peter Sellers in Ter Millionairess, ``1960 Her: Oh doctor, I'm in trouble. Him: Well, goodness gracious me. Her: For every time a certain man Is standing next to me. Him: Mmm? Her: A flush comes to my face And my pulse begins to race, It goes boom boody-boom boody-boom boody-boom Boody-boom boody-boom boody-boom-boom-boom, Him: Oh! Her: Boom boody-boom boody-boom boody-boom Him: Well, goodness gracious me.
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