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After a short summer simmer, polyclinic politics promise provincial pyrotechnics – Health Policy Today, 20th August 2008

GPs you see today might have a spring in their step.  The BMA aims to enlist local authority Overview & Scrutiny Committees in their war on polyclinics. Reports of a Lancet paper suggest the new GP contract has rapidly eroded inequalities of care in just three years. We are even told that the news prescriptions rose in Wales by 5% (in the first year since charges were scrapped) is a good thing and testament to the success of GPs better managing chronic conditions, giving more medicines so less is spent on hospital admissions.

Something tells me that the not-long-simmering political tensions in primary care are about to return to the boil.


Having written about rationing every day for a week and a half, it is nice to turn to something different, in the shape of a familiar subject, GPs views towards polyclinics.

Healthcare Republic report that the BMA is to launch a second front in their war on polyclinics.

GPC member, Dr Prit Buttar told GP that the BMA would ensure the momentum is maintained by launching a follow up strand to support existing surgeries.  The campaign will focus on Overview and Scrutiny Committee members, raising questions about PCTs' polyclinics plans. He said this presented a great opportunity for the committees to play a bigger role in local health decisions “and ask, how is this value for money”.

Overview and Scrutiny Committees exist to explore public concerns about plans, and the BMA will draw on the fear that has been raised in the public minds by the first stage of the campaign. 'It is now firmly in the public conscience that this will be a threat. The public aren’t stupid, they know funding is limited. PCTs will face financial shortfalls as payment by performance in hospitals takes off and they have to run GP-led health centres – this will end up costing £3 million more.’

GPC chairman Dr Laurence Buckman is quoted as saying the next stage is “imminent”. ‘We are finalising mechanisms and funding at the moment. We are interested in getting patients to influence local governors about the siting of polyclinics and walk-in centres.  

It is easy to see how this might become a successful strategy, in terms of defending the sovereignty of existing practices.  There will be concerns about some polyclinics – the entrance of the private sector and the erosion of continuity of care. In some areas, the dominant local view might be to invest the money that would have been spent on polyclinics in alternative ways. But very often there may be a difference of views. What is essentially lacking, locally, is the means to resolve these political debates in a way that local people feel is fair.

The logic of Government policy is to devolve more decision-making.  The thrust of the Darzi review is of more clinical leadership locally.  Therefore, there is some logic in having a body that can oversee the decisions and act on behalf of the public.  But it may require a political maturity that is not in place, as Overview committees are still relatively new.  Their relationship with local authorities and health partners is still not very clear, remaining quite local in character.  How will they manage the existence of polarised views in local areas?

The question is this: are local authorities prepared for the global warming of health politics in their areas?  June’s White Paper on community involvement gives the PCT the role of coordinating local petitions that relate to the PCT.


Another front in the BMA’s war against polyclinics relates to research evidence finding that the new GP contract is reaping benefits.  

Research published in the Lancet last week, written by researchers from Manchester University’s National Primary Care Research and Development Centre finds that the  Quality and Outcomes Framework (QoF) has helped to reduce inequalities.

The researchers divided 7,637 GP practices into five groups, based on a deprivation ranking.  They then monitored their relative performance on 48 clinical indicators over three years. Although practices in affluent areas continue to perform better, the gap between the groups narrowed substantially, from 4.8% to 0.8% during this period.  In 2006/7 practices in the most deprived areas were achieving 90.8% of scores against 91.2% in the most affluent areas.

The authors conclude, “the use of financial incentives seems to have the potential to make a substantial contribution to the reduction of health inequalities.”

This is hard to dispute, and reinforces other findings.  The downside of QoF, as shown by a BMJ study, also published this week, is that it focuses GPs attention tightly on the indicators that are rewarded in the contract, meaning that other conditions, particularly important to the frail and elderly are downplayed in comparison.  The BMJ research found relatively weak management of osteoporosis, for example,


Research finds that financial incentives work and this message is further reinforced by figures from Wales, one year after prescription charges were abolished.  The number of items dispensed increased by 2.9m, a rise of 5% (the equivalent to 20 items per person).  

The trouble is, we cannot be sure, what incentives are being supported - is it a greater demand, resulting from the removal of obstacles, or is it an indication of a new form of clinical management?

The causes are not easy to read.  This is the fifth year in a row that dispensed items have increased - i.e. it is the continuation of an established trend.  Secondly, Wales has more patients with long-term conditions and it the rise may be another illustration of the effectiveness of the GP contract.  

Welsh CMO, Tony Jewell says the reasons are, “we are issuing more medicines used to treat cancers, as cancer therapy has improved to a point were, for a number of patients, it is now a chronic condition, plus GPs are helping more patients manage their condition under new enhanced contracts”.

Unfortunately, we have little evidence with which to substantiate these claims.  For all the claims about becoming a health promoting service, encouraging self-management and so on, as yet we lack any evaluative framework or database that is able to capture whether these approaches are saving money.

Politics always fills evidence gaps.  Without being able to demonstrate a change in clinical management, the CMO’s interpretation will be challenged.  The Welsh Lib Dems dispute the claims.  “We warned that giving free prescriptions for all would be disastrous and today’s figures have vindicated our position.  The cost of this gimmick will be with Welsh patients for generations”.