Farewell to the family doctor?

What is the Government proposing?
Over the next ten years or so it wants to set up around 300 'GP-led health centres', or 'polyclinics'. These would be staffed by 25 GPs and a range of other specialists - dentists, nurses, mental health experts, midwives, to name a few - who could provide up to 50 per cent of the outpatient treatment (X-rays, ultrasound, blood tests, minor surgery) now carried out in hospitals. They'd be open from 8am to 8pm during the week, offer weekend appointments and, in theory, enable patients to see a doctor more quickly, possibly without an appointment. Patients could collect prescriptions, get screened for diabetes, have an eye test and so on... all in the same building.

What was the spur to this proposal?
The Government has long wanted to get resources out of hospitals and back into the community, with more emphasis on early prevention and less on emergency repair. (At present the nation's 8,500 GP practices do 90 per cent of NHS work, yet hospitals take 80 per cent of the cash.) Another motive is to get a grip on the minority of GPs (as many as 15 per cent) judged seriously inadequate. The latter tend to run single-handed practices in shabby premises in poor areas, and are concentrated in London. Hence initial plans for polyclinics were confined to London, which is to have 150. There are now plans for a further 150 to be distributed across England, roughly one for each Primary Care Trust outside the capital.

How did the polyclinic idea originate?
It owes its inspiration to Christoph Wilhelm Hufeland, a 19th-century Prussian doctor who once treated Goethe. In 1810 he founded a polyclinic where patients from poor families could see doctors, get treated and go home, so avoiding the exorbitant cost of a hospital bed. The system, increasingly associated with Socialism, was banned by Hitler, but flourished in communist eastern Europe and in countries such as Cuba which, though one of the world's poorest nations, has excellent healthcare. More recently, however, it has been gaining ground in the US, France and Germany. The latter has some 400 polyclinics, offering minor surgery for conditions such as varicose veins and hernias as well as standard primary care. "Doctors, all plugged into the same computer system, can swap information on patients," says Rainer Jeniche of Germany's polyclinic association, who claims it costs an average of €50 a day to treat someone in a polyclinic compared with €350 a day to treat them in hospital.

And have any been established yet in the UK?
Yes. Under the NHS's 'Lift' programme, a type of private finance initiative, several 'supersurgeries' have been built. At the Brocklebank Health Centre in Wandsworth, for example, 15,000 patients under the care of 13 GPs have access to chiropody, speech therapy, anti-natal care, family planning, minor surgery, etc. But a report by the independent King's Fund into such schemes says the absence of clear local leadership often frustrates integrated care, so that long-standing divisions between GPs and specialists remain.

And do GPS favour polyclinics?
No. A poll in the doctors' magazine Pulse shows just 8 per cent say their area needs a polyclinic; one in three GPs would refuse to work in one. That's in part because many GPs fear competition from the big private companies that would run some of the new centres, and worry that they'd lose control over their practice's biggest asset - its building (a factor that explains why so many practices tend to be located in richer, leafier areas rather than where they are most needed). But GPs also have less self-interested grounds for concern. The BMA (the doctors' union) fears that the new clinics will force traditional GP practices to close and in the process destroy the personal link with (and proximity to) the family doctor that patients set such store by. And when big private companies run the polyclinics, says the BMA, patients won't get continuity of care, as the salaried doctors the companies employ are unlikely to stay in one place for any length of time. Meanwhile the Tories estimate that 1,700 of England's GP practices will have to go. But the Government accuses the BMA and the Tories of scaremongering and claims the new polyclinics will complement, not replace, existing practices.

So who is right?
It depends whether the new clinics follow the 'supersurgery' model, which involves dismantling existing GP surgeries and relocating their services in one big unit; or the 'hub and spoke' model, where most existing practices continue but share access to a set of new services in one facility. The King's Fund supports the 'hub and spoke' model, which would allow people to keep their family doctor (the 'spoke') while providing them with a 'hub' to handle diagnostics, unscheduled calls, and teams of specialists. But the thrust of Labour's plan seems to favour the supersurgery idea. NHS organisations in London already have plans to close more than 100 GP surgeries to make way for polyclinics. And though Health Secretary Alan Johnson insists GPs will stay in control, he is quietly binning a payment, the minimum practice income guarantee, designed to protect GPs operating alone.

But will the new polyclinics save money?
Junior health minister Lord Darzi insists that the polyclinics will be cheaper than the hospital care which they are intended to replace, and predicts that the NHS will be able to save around £1.5bn a year in London alone. But experts think this is highly questionable. The NHS will save money if hospitals strip out costs on overheads and activities being moved to polyclinics, but on past experience that's unlikely. Far more probable is that the new services will fail to reduce demand on hospitals and that their costs will supplement, rather than substitute, hospital costs. ·