Do polyclinics spell the end of the patient-doctor relationship in favour of faceless big business intrusion into health services? Or are they the must-have health facility of the future?

While the debate looks set to rage on beyond the publication of Lord Darzi's final report, we are in danger of overlooking two crucial questions. At what level should decisions about polyclinics be taken and who should be involved in the decision-making process?

We are told repeatedly by ministers that localism is at the heart of the government's health reforms. In May, Lord Darzi issued five pledges to the public and staff on how the NHS will handle changes to services, which included the commitment that all changes will be locally led on the basis that "local needs are best met by local solutions".

But Lord Darzi's review contradicts the rhetoric. The fact is that the Darzi review expects all areas to develop polyclinics - either through co-locating services or by networking services on different sites - irrespective of local variations in existing service integration, local health needs and geographical factors.

Questionable benefits

Research by the King's Fund questions whether polyclinics will actually deliver improvements in quality, accessibility and costs. The case for polyclinics appears particularly shaky in areas with dispersed populations where people may have to travel much farther to GP services.

A wide range of commentators have already noted that the concept of the polyclinic has been interpreted to encompass almost any clustering - virtual or actual - of services. In many areas, this emotive term has been dropped in favour of super-surgeries, integrated health centres, community hospitals or health and well-being centres.

Many different models have been proposed, incorporating an almost infinite array of diagnostic and treatment services, such as minor surgery, social care, health advice and chronic disease management.

Local matter

But whatever they are called and whatever the proposed reconfiguration and degree of service integration, this is essentially a local issue and it needs to be accountable to local people.

So who should be involved in local discussions about the best solution for local communities? Apart from the campaign by the British Medical Association, there is little evidence that local people or their elected representatives are being involved in early discussions about the future shape, direction and development of community-based health and well-being services.

It is therefore no surprise that 1.2 million people have signed the BMA petition when they feel they have no real influence over what may replace existing services.

The Local Government Information Unit's discussion paper, Out of Our Control? The case for better health accountability, sets out ways for the community and their elected representatives to gain greater influence over the planning, delivery and review of health services. It recommends that health overview and scrutiny committees are given more prominence and capacity to hold commissioners and service providers to account.

Wider debate

Lord Darzi gives assurances that local authority health overview and scrutiny committees will have the opportunity to scrutinise plans for reconfigured health services but often their involvement occurs at too late a stage in the planning process to have any real influence.

Before any concrete plans are put forward, primary care trusts need to engage local councillors and communities, through local involvement networks, in a wider debate about their health priorities, the accessibility of existing services and how far they wish health and other public services to be integrated or networked.

The Darzi review could mark a new dawn in local involvement and influence in health services, or it could represent another top-down initiative that disregards local needs. It is only by engaging in an open and honest debate at local level that we can avoid the latter outcome.