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In all the interest over the coalition government's proposals for the NHS, often described as the biggest shake-up of the health service for decades, earlier attempts at reorganisation are being fast left behind.
But in one part of north east London, the NHS in Redbridge has been quietly building on the vision of Lord Darzi, the previous government's health minister whose review of the NHS proposed reorganising local services into specialised 'polyclinics'.
In Redbridge, that is now a reality. Health services in the area have been reorganised into five centres, or 'polysystems', each serving up to 70,000 patients. Polysystems are based on a collaborative and local partnership approach. They became operational last spring, well ahead of the government white paper and have work programmes in place for their first year, with projects including new ways to deliver services to patients with coronary artery disease or diabetes.
Managing the resource
Conor Burke, interim chief executive of NHS Redbridge PCT says it has taken two or three years to develop the present system. "We have recognised that they only way to keep people well and healthy is for our GPs to take the leadership position and recognise they are part of managing the resource," he comments. "I can give them the information and some of the management skills they need to help them prioritise, but ultimately this is about how they make the decisions. Just getting people to think in that way has been possibly the biggest challenge, because it's a different way of thinking."
Burke says the lessons from service reorganisation in Redbridge will be useful to other NHS areas. In particular, he cautions against thinking such radical moves can be done quickly. "It has been a two- or three-year journey and has taken quite a lot of effort to get to here, which is about halfway to where we want to be," he says.
There are about 150 GPs in Redbridge, working in 49 practices. The new polysystems provide GPs with a clear infrastructure through which to operate, according to Burke. "The next step is to execute the plans and demonstrate to local residents and to GPs themselves that they can drive this agenda and deliver improved outcomes."
Redbridge does face a risk, acknowledges Burke, of being held back as the government unveils its healthcare reforms. "We want to continue at this pace. I imagine most other PCTs are still at the hearts and minds phase and there is a slight concern that the world is about to change and everyone is waiting for the guidance. That can create inertia. But we want to go on. Locally, we are saying we won't wait."
Dr Narinder Sharma has been a GP in Redbridge for more than 10 years and is a principal in a GP practice working with one of the borough's polysystems.
The Loxford polyclinic is London's first fully-functioning polyclinic. Dr Sharma sees a natural progression from Lord Darzi's vision for transforming primary care in London, with a hub and spoke model, where the polyclinic forms a hub for local GP practices. "The new coalition government places less emphasis on the buildings and structures of polyclinics and more emphasis on GP-led commissioning, but you could use the term polysystem as another word for a commissioning cluster," he explains.
Ahead of the game
In a diverse area, ethnically and socially, with quite a lot of deprivation, resulting in health, social care and housing problems, the polysystem approach provides coordinated care, says Dr Sharma. "Compared to other parts of the country, we feel a bit ahead of the game," he says. "It's not rocket science. Having a polyclinic just down the road means patients can be seen more quickly that through the traditional route of seeing your GP and being referred to hospital and then making a trip of several miles to an outpatient clinic."
Dr Sharma acknowledges that initially, some GPs have been apprehensive about the changes. "There was a mixture of interest in the opportunity for clinicians to be in the driving seat, but apprehension about the transfer of risk or blame. But I take a pragmatic view. It does make sense in some shape or form to have GPs working closely with managers. In the white paper, GPs will be the decision makers and they will be able to see both sides of the coin. They understand clinical decision-making, but they also see the impact of financial decisions."
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