The publication last year of the NICE guideline on antenatal care,1 and the introduction of the new GMS contract 2 should make practices ask some hard questions about the services they offer and, perhaps more to the point, should offer in the future.
The NICE guideline has already galvanised most maternity service providers, which are almost exclusively units based in district general hospitals, to examine the pattern of service they offer and adjust their provision to bring it into line with the NICE recommendations (see Figure 1, below).
With few exceptions, services in GP practices will be expected to fall in with locally defined patterns of shared care, which are usually midwife-led.
|Figure 1: Algorithm for the routine care of a healthy pregnant woman|
|Figure 1 continued|
Reproduced from Antenatal Care: Routine care for the healthy pregnant woman, by kind permission of the National Institute for Clinical Excellence
Most GPs will be aware that antenatal care falls into the contract’s additional services section, and so a proportion of the payment is made through the global sum. This amount will be the uplifted historical payment the practice has received for maternity medical services. This amount is augmented by a meagre six points available through the quality and outcomes framework.
The six quality points are available under a single maternity services indicator, MAT 1, which specifies that "Ante-natal care and screening are offered according to current local guidelines”.
The additional services section does not cover intrapartum care, and GPs engaging in this work must negotiate payment for it as an enhanced service.
GPs should meet with their midwife colleagues to determine how they will participate in providing the service and to ensure that what is planned accords with best practice. Box 1 (below) provides a checklist for such a discussion.
|Box 1: Maternity services action plan|
A variety of models of care are used by different practices. These may be doctor-led antenatal visits, an agreed pattern where visits are shared with the midwife or perhaps complete devolution of normal antenatal care to the midwife unless medical or other problems require the GP’s expertise.
The NICE guideline contains detailed recommendations on care and they can be adapted to suit local needs and opportunities – care in rural locations is likely to differ greatly from that offered in towns.
The GP’s role
Ideally, the GP’s role should start with pre-pregnancy advice including a discussion of lifestyle measures to optimise the woman’s health before she becomes pregnant and to help identify any risk factors. At such consultations GPs could offer advice about smoking and alcohol and identify potentially hazardous prescribed drugs. Advice can also be given on the implications of any adverse past medical or family history.3
Once the woman becomes pregnant, the GP can advise on what local services are available and discuss a range of options such as home delivery, water birth and anaesthetic measures.
The key elements of the NICE guideline should form the basis of care (see Figure 1, above):
- Evidence-based information must be available to pregnant women so that they can make informed decisions about their care. This should include details of where, and by whom, care will be undertaken. Continuity of care by a small group of professionals should be assured.
- In the case of uncomplicated pregnancies, a schedule of seven antenatal appointments for parous women and 10 for nulliparous women should be sufficient.
- Women who may need additional care should be identified early.
- Women should be offered an early ultrasound scan to determine gestational age and detect multiple pregnancies.
- Screening for Down’s syndrome should be offered, using a test which provides a detection rate above 60% and a false-positive rate of less than 5%.
- Screening for diabetes mellitus should not routinely be offered.
Once the woman has discussed the options with her GP and they have agreed on the pattern of care, local policy together with the capacity of the practice and the GP’s workload will determine how much GP involvement will be required.
In our practice the NICE guideline has brought about evolutionary changes, led by the local maternity unit. A wider range of routine screening tests is being offered. In addition, there has been greater clarity over care pathways so that each member of the team, and the woman herself, is aware of what should be done and when it should be done.
Although this element of primary care is important and professionally rewarding, of necessity many practices are focusing on meeting objectives identified elsewhere in the new contract. However, with a well organised and supportive local maternity unit, a practice providing this service will have few costs but many potential benefits. Routine clinical care is relatively simple and aided by a concise guideline. Most women welcome active interest and involvement from their GPs during pregnancy,4 and this can strengthen relationships and provide opportunities to make long-term positive health interventions within families. The service may also help to attract new patients, particularly young families, and enhance a practice’s positive image.
- National Institute for Clinical Excellence. Antenatal Care: Routine care for the healthy pregnant woman. NICE Clinical Guideline 6. London: NICE, 2003.
- Investing in General Practice:The New General Medical Services Contract. www.bma.org.uk
- Heyes T, Long S, Mathers N. Preconception care: Practice and beliefs of primary care workers. Family Practice 2004 21: 22.
- Villar J, Khan-Neelofur D. Patterns of routine antenatal care for low-risk pregnancy. Cochrane Database of Systematic Reviews 2003; (1).