Saving Mothers' Lives: - Public Health Agency for Northern Ireland

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17 Issues for General Practitioners
importance of verbal cues and focussed history-taking need to compensate for the inability to examine the
patient. The BMA recommends that:
“consulting over the telephone should normally be modifi ed to allow the patient greater time to
explain their problem. The doctor should also take a detailed history and seek the answers to all
the relevant direct questions. There should be a summation and agreement with the caller/patient
as to what exactly the problem is that the doctor is attempting to solve. The doctor should explain
their assessment and detail the action s/he intends to take. If it is not possible to safely manage
the patient over the telephone, the doctor should arrange a face to face consultation and make
an appropriate referral 11 .”
Doctors may need specifi c training in telephone consultations, an area that is currently neglected in the
training and professional development of GPs 12 .
Referral letters; providing complete information
General practitioners are the only professionals who have access to a woman’s complete medical history
and as such are the only health professionals able to provide a complete medical, psychiatric and social
history. It is therefore crucial that all relevant information is included in referral letters to enable appropriate
and planned care. These Reports have regularly highlighted examples of where inadequate information
in referral letters led to adverse consequences for pregnant women and this triennium is no exception. A
GP has a responsibility to ensure that any relevant history is conveyed in as much detail as possible to the
midwife and/or obstetric team who will be caring for the woman during pregnancy.
Strategic changes in delivery of care
Increasing midwifery-led care
There have been several changes in service delivery over the period of the Enquiry which provide
challenges in caring for pregnant women. The recent implementation strategy for the National Service
Framework for Maternity Services13 , “Maternity Matters” 14 in England will result in all low risk women being
offered a choice of midwifery-led care before, during and after childbirth. The lack of fi nancial incentive
for GP involvement in obstetric care under the 2004 GP contract has also led to many GPs becoming
more distanced and less involved in maternity care. Maternity care has traditionally been a valued part of
a GP’s work, so they have often been unhappy about this change. For the period of this Enquiry only 3%
of the women who died were reported to be receiving care “shared between midwife and GP” and this
direction looks set to continue. This therefore raises some crucial issues for GPs and midwives in providing
maternity care.
Booking low-risk women
One challenge is how a woman can be judged to be “low risk” at booking. Following a fi rm recommendation
in the last Report about this, the National Institute for Clinical Excellence is preparing generic consensus
guidance on this, which is due to be published in early 200815 . There may be medical, mental health or
other problems that a woman may not appreciate, whose importance she does not understand, or that
she fails to disclose. The GP is the only professional who has access to a woman’s complete medical
history. In addition a GP has particular skills in understanding and managing risk, handling uncertainty
and recognising the early stages of disease. In order to undertake a proper risk assessment midwives
need access to the electronic and paper GP record. If this is not possible GPs should be willing to give a
copy of the medical summary to either the woman or the midwife and to discuss any issues that may be of