As health minister Lord Darzi undertakes a major review of the NHS, an editorial in this week's BMJ assesses which options are most likely to produce an effective, efficient, and patient centred health service.
The review needs to strengthen primary care, writes Martin Roland, Director of the National Primary Care Research and Development Centre. The UK system of universal registration with a single general practitioner must be retained, even though patients may occasionally consult other practitioners, for example, a doctor near their workplace.
In terms of polyclinics, which provide a range of services under one roof, Roland believes that providing good premises and facilities in highly deprived areas could make a big difference to care. However, he points out that the NHS goal of increased patient choice requires more high quality practices, not the small number of large practices that some polyclinic models suggest.
Some models for polyclinics also include a greater role for specialists working in the community (bringing services "closer to home"), and government policies are already moving specialists out of hospitals and training primary care staff to take on new specialist roles. However, specialists may be less efficient when deployed outside hospitals, warns Roland.
Better support is also needed for patients with long term conditions, and several changes are necessary to improve continuity and coordination of care for patients with multiple conditions, he adds.
Vigorously pursued policies may deliver on their stated goals but have other unintended effects, he argues. For example, strategies designed to reduce waiting times to see general practitioners have made it more difficult for patients to book in advance.
He concludes: Now is the time to look at both the system and the patient as a whole. That is the challenge for the Darzi review.