Tomorrow’s world

To be perfectly honest, I am getting very confused here. I was beginning to think that a picture is starting to emerge of how the government sees the future shape of NHS services delivery, but all of a sudden everyone seems to be seeing a different image. We are led to understand that it will be bigger and better, but right now ‘bigger’ appears to be the only certainty.

If Lord Darzi has his way, aggregation of medical services is the way forward. Fewer, bigger sources of healthcare,

delivering (we are told) higher quality services through a concentration of excellence. Everyone wants quality, but is the government really prepared to pay the financial cost, and the public the human cost of achieving it? And will the ultimate cost be paid at the ballot box? The vision for ‘polyclinics’ may be big, well-equipped, and well-staffed (and cost effective) but will they also be friendly, personal and locally accessible, because that’s what patients want? Has the government given up on the idea of a highly personalised, locally focused, warm and fluffy ‘patient experience’? Apparently not, because Lord Darzi has stated: ‘People want healthcare that is more personalised and convenient.’

Alan Johnson, Secretary of State for Health, added: ‘We are opening 150 new GP-run health centres, open from 8am-8pm, seven days a week. Because this programme is all paid for with new money, none of it will lead to a reduction in traditional GP services.’

He maintained: ‘We are not imposing super-surgeries (‘polyclinics’), or replacing the existing services… this is about traditional access and extra choice for everyone.’

But the King’s Fund is less convinced. While recognising that there were some real opportunities that were worth exploring in this proposal, its chief executive Niall Dixon observes: ‘A major centralisation of GP services into polyclinics could make it more difficult for patients to visit their GP, especially those living in rural areas.

‘Bringing together large numbers of GPs in the same building was no guarantee that they worked together more cost-effectively, and to the advantage of patient care.’

But, in the meanwhile, every PCT was handed down instructions from the Department to ‘complete’ procurements (of at least one super-surgery) during the 2008/2009 financial year. This was further confirmed in a parliamentary written answer from Ben Bradshaw, the Health Minister. Furthermore a Labour Party press release stated that the new centres would be built ‘in every town and city’.

Little and large

A lot has been spoken about the ‘patient journey’. Anyone who needs to be taken in an ambulance to the nearest operational A&E Department can look forward to one.

In some parts of the country, it could be a very long one, so my advice would be to bring along some warm clothing and some books to amuse yourself on the way. The collected works of William Shakespeare or the Encyclopaedia Britannica should do the trick.

In NHS primary dental care, the single provider working alone is now frowned upon in all but those areas where this is the only way that service provision is likely to be maintained. Single-handed practice is certainly not in the government’s picture of the future and, on instructions from above, PCTs only agree to new single-dentist contracts as an absolute last resort.

But for many patients, the alternative of the single-handed practice delivers just that – the personalised service and predictability and reassurance of knowing exactly who you are going to see – and with a fair chance of recognising them when you meet up.

A recent British Medical Journal article reported that: ‘Patients in small practices rate their care more highly in terms of both access and continuity and these practices achieve slightly higher levels of clinical

quality than the larger practices.’

It gives some patients (and some practitioners) the starkest possible choice between the smaller, personalised ‘free-range’ option (which will increasingly be delivered privately, it seems) and the ‘battery farm’ option that numerous patients’ opinion surveys confirm is not what most patients want.


The economies of scale – achieved by aggregating service delivery into cost-effective and resource-effective units (typically two-four clinicians minimum) – is well-documented, and not exactly new science for the corporates in their acquisition policies.

But there is often a downside in terms of patient experience. It can easily get drowned in the cacophony of stated upside benefits, but the announcement of new health policy initiatives tends to be made with the volume turned up, while the same initiatives go out of fashion in whispers.

NHS Direct, Access Centres, and the Independent Sector Treatment Centres (ISTCs) are but three initiatives whose cost-effectiveness does not bear rigorous scrutiny. In some cases, they have turned out to be a costly disaster for the public and for the taxpayer.

A spokesman for the BMA’s GP Committee

recently said of the proposed ‘polyclinics’: ‘This is another government plan that is potentially going to waste hundreds of millions of pounds of scarce NHS resources, creating very large health centres that many areas of the country simply don’t need or want.’

Obviously, the BMA is bitterly opposed to Lord

Darzi’s plan because they can see only the rapid

demise of the traditional family practitioner and

his/her close relationship with the local community that they serve. More cynically, they see the erosion of autonomy and the progressive loss of the shape of

traditional practice.

If the small GP medical practice cannot

compete, it will be forced to close.


Is this also the future of NHS primary dental care? As a profession, we are only now coming to terms with the new world of NHS dentistry and local contracting and commissioning. Instead of individual contractors offering to do as much, or as little, NHS dentistry as they choose to (as in the distant past), and instead of independent contractors offering to provide continuing care for a number of patients of their own choosing (as in the recent past), we now have the PCTs in the position to choose how much dentistry they wish to commission, from whom, and on what terms. This is a very different world. In truth, the choice is no longer in the hands of the patients, nor in the hands of the practitioners, but in the hands of those who hold the budgets. If the

practitioners (or the patients) wish to vote with their feet, they are free to do so and don’t expect too many shouts of horror from the government in either case. The PCTs may look in puzzlement at the individual pieces of the jigsaw that they happen to be holding at the present time – but only the Department of Health holds the lid to the jigsaw puzzle, which reveals the ‘big picture’ of what it should all end up looking

like. But we are starting to get a glimpse of this. Or at least… I think we are.

Kevin Lewis is speaking at the Private Dentistry National Conference on Thursday 27 November 2008 at The Hotel Russell, London. The event will provide you with the tools to develop your practice and make it more profitable by bringing you and your team fully up to date on the latest developments in private dentistry.

For further information and to book your places, please call 0800 371652 or visit the website at

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