We need to revisit integrated health centres to deliver a better service than today’s fragmented system, says Justin De Syllas
The idea of publicly provided health centres started to take shape in the minds of reformers in London a century ago, and the earliest architectural proposals appeared in the Dawson Report of 1920. Dawson’s approach was not adopted but the concept of the multifunction health centre was developed and refined in the 1930s and was seen by many as being, with the hospital, an essential part of the infrastructure for a future public sector health system.
Each neighbourhood was to have a centre providing a full range of preventative, public health, primary and social services where GPs would work in teams alongside other disciplines. A number of centres would be attached to a hospital providing inpatient care and specialist back-up. The staff of both would be employed by the same administration to facilitate a planned and coordinated local service.
This model was adopted as policy by the Labour Party in opposition in the 1930s, but when the National Health Service was established after the Second World War, for political reasons this consisted of a number of separately financed and administered organisations: a national hospital system; local authority-run preventative, public health and social services; and independent GPs, dentists, opticians and pharmacists contracted to the NHS.
The NHS Act required local authorities to provide what became known as comprehensive health centres but the initiative was opposed by the medical profession and only one of any size was built, the John Scott Centre at Woodberry Down in London, which opened in 1950. Otherwise it proved impossible, within the financial and political constraints of the time, to implement the health centre policy. Instead small public sector local health centres with a limited range of services were provided, often not containing family practitioners. Many GP practices preferred to acquire their own premises, using government subsidies, rather than work in a health centre. This fragmented arrangement led to a serious lack of coordination between different organisations providing care.
There was, however, a revival in England of the idea of the comprehensive health centre at the beginning of the 21st century. Primary care trusts (PCTs) – providing health services – were encouraged to form partnerships with local authorities – providing social care – to deliver an integrated service. The partnerships commissioned multifunction health centres to accommodate a wide range of services under one roof, one of the earliest and largest of which was the Heart of Hounslow Centre for Health in London by Penoyre and Prasad, which opened in 2007. Where local GP practices declined to move into these centres salaried GPs could be employed. The priority was to locate the centres in areas, such as the inner cities, where community care was most in need of expansion.
Despite the attempt by the government advisor, Ara Darzi, to provide a stronger intellectual foundation for the comprehensive health centre, which he called the polyclinic, the rationale behind the initiative was compromised by the introduction of competitive tendering for clinical services by any qualified public, private or voluntary sector organisation. This threatened to turn the centres into competing health supermarkets rather than bases for a planned and coordinated public service.
The Coalition Government made a further attack on integration by disbanding the PCTs and strategic health authorities, putting an end to the commissioning of comprehensive health centres in England. Soon some new centres, such as Kentish Town in London by AHMM, found services being withdrawn by the local authority partner which could no longer afford to run them.
The revival of the idea of the comprehensive health centre was not exclusive to England, however. A parallel development took place in the devolved health services of Scotland, Northern Ireland and Wales. All three countries have been moving towards the creation of a more unified health administration, providing a more integrated service, and all three have a programme of new health centres as part of a rationalisation of public sector service coordination and delivery. Although thorough assessments of these buildings in use are still lacking, the best of them demonstrate that well designed buildings, in the context of a coordinated model of care and delivery, can make a positive contribution to the efficiency of the service and the experience of both staff and patients.
Hopefully the devolved services will show that the comprehensive health centre has a role to play in an integrated public sector health and social care system and will continue to resist pressure from Westminster, the international private healthcare industry and many in the medical profession to move towards an American-style market for health services. Those who believe in a publicly provided health system must look to them to demonstrate that a more unified public sector health administration can outperform, in terms of both cost and quality of care, the fragmented market of competing providers being promoted in England.
Justin De Syllas is the author of the book Integrating Care: the architecture of the comprehensive health centre, recently published by Routledge