Which way forward for GP shared maternity care?

Doug Hendrie

6/12/2018 1:21:51 PM

Dr Wendy Burton is raising the alarm over threats to shared antenatal care.

Shared maternity care is under threat. What can be done?
Shared maternity care is under threat. What can be done?

Shared antenatal care among GPs, GP obstetricians and other healthcare professionals is breaking down, according to Dr Wendy Burton, Chair of the RACGP Antenatal/Postnatal Care Specific Interests network.
Some GPs and GP obstetricians report effectively being cut out of hospital-based maternity care altogether.
‘I am hearing from GPs around the nation that they are being pushed out of providing care to women who they have an existing therapeutic relationship with, in exchange for hospital-based care which typically concludes six weeks or less following birth,’ Dr Burton has said.
newsGP asked Dr Burton about the best path forward for shared antenatal care.
Are you happy to see other medical peak bodies speak out on the issue?
I am pleased to see our colleagues engage, like Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) and the Australian Medical Association (AMA), and particularly pleased to see so many GPs engaged. It’s important to get the different voices heard.
That’s one of the difficulties we’ve faced over the years; how to make our voices heard, how a GP in Rockingham or Kalgoorlie can say, ‘Houston, we have a problem’. So it’s terrific to see that, and to see our colleagues support what we’ve been saying. There’s not enough attention to using the GP and GP obstetrician workforce effectively.
I am past alert – I am alarmed about what’s happening to GP shared care around the nation.
What are you hoping will happen now?
I’d like to see broader conversations about working together, not just with medical but also with our midwifery colleagues. If [maternity care] is being redesigned, how can we do it in a way that has a broad workforce inclusive of GPs and GP obstetricians?
I sit on the advisory group for the National Strategic Approach to Maternity Services, which is a national review currently underway. The RACGP, RANZCOG, AMA, the Rural Doctors Association of Australia (RDAA) and the Australian College of Rural and Remote Medicine (ACRRM) all have voices at that table.
It’s important that the message we’re giving is consistent. There are a lot of people of goodwill in the meeting and I suppose that most of us also have very clear agendas. I’m cautiously hopeful we will advance the conversation. But, then, I’m an optimist.

Wendy-Burton-Hero.jpgDr Wendy Burton wants to raise the alarm about threats to shared care.
What is the ideal role for GPs in maternity care?
The best of the GP model, in my opinion, provides broad-based, comprehensive, evidence-based, long-term, relationship-building intergenerational care. It’s about seeing women before, during and after pregnancy.
Our continuity of care can be measured in decades and generations.
Establishing relationships matters during the birth, but also for early parenting and beyond. We spend a lot of attention on the birth, which certainly is important, but care before and after birth is important, too.
Are there any guides for Australia in how other countries have approached the issue?
We often look at the UK or New Zealand for our models, but that just doesn’t work across the whole of Australia.
Geographically, we’re more like Canada. Western Australia is our largest state, Queensland has higher levels of regionalisation with more birthing towns, and the Northern Territory has complex issues of its own. With a small population and a large land mass, we need to chart our own course.
Why have these issues arisen?
Where do I begin? There are turf wars, gender wars and history behind what is happening in maternity, and the culture can be devastating and diabolical. It can be gut-wrenching what we’re doing to each other, with both horizontal and vertical violence. Doctors to doctors, midwives to midwives, doctors to midwives and midwives to doctors. It’s wicked. There are layers upon layers of issues. It’s not simple. It’s intense and it’s complicated.
I believe that all of us do want to be working in the best interests of women and families, but each of us bring our own lens to how we do that and what it means.
One of the shortcomings with our system is that most hospital doctors have never worked outside of one. Every GP who trained in Australia has worked in an Australian hospital, so typically we understand their pressures better than they understand ours.
We need to be having conversations about how to build cost-effective, robust medical services so no door is a wrong door. However a woman comes across a health professional, at the very least, they should be able to point her in the right direction and give her correct, helpful information. The only effective way I see us doing this is together.
We need to be working a whole lot better as a team. Conversations need to be had – both the ones in private, and in the medical media – around how we make this better without it getting all political and nasty.
Why are we seeing these issues now?
My parents were country GPs and they delivered most of my childhood friends. They knew everybody. There was no divide, no clinical handover issues. Dad and mum admitted their own patients to hospital and, when necessary, they knew personally most of the specialists they’d be referring to. So they were leveraging personal relationships.
But, as a consequence perhaps of busier, bigger cities, we are losing these professional interrelationships. I don’t know who’s in charge of the ED at my local hospital. I don’t know all the cardiologists or gastroenterologists.
As we lose those personal relationships, the question is, can we build a culture that works both ways [between GPs and hospitals] and, if so, how?
We’re missing a lot of this critical clinical handover conversation, and it’s not just maternity.
The information in the referral coming with the patient should be my clinical handover – these are my concerns, here’s the patient history, clinical assessment and what’s been done to date. And when patients come back from hospital, there should be information – this is what we found, what we did and what we’d like you to do.
The health of the nation depends on us getting this right, it is so important. Women and families deserve no less than our best.
We have to get better at getting along better. We have to try and put aside our tribal differences and concede that none of us know it all.
I know that I am tackling human nature and that’s where my optimism gets checked. As well as everything else, we’re battling self-interest, tribalism and the inability to see beyond our own frames of reference. And yet if we’re going to do our society proud, we need some decent long-term planning.
Chronic disease prevention starts pre-conception, with the health of the mother and father before the child is even conceived, the environment of the pregnancy, the environment growing up. There are long-term health outcomes to be considered.
[Medical] fragmentation is doing my head in. We have women who see a physician for asthma, an endocrinologist for diabetes, a midwife for an antenatal visit. All those things matter, but at the end of day we are dealing with one complex and at times complicated person and someone has to put it all together, and work out with her and with her consent, what’s best for her.
I believe we need more generalists who can work with specialists and not more and more specialists working by themselves and not communicating with each other and with the broader team.
Truth is, I don’t believe we’re doing that as well as we could. I want best, but it simply starts with better. We’ve got good, and we should be going for gold.

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judy hesse   7/12/2018 9:31:11 AM

couldnt have said it better myself -with advent of midwifery group care at SCUH i have effectively been cut out of care of my pregnant patients even when i refer for shared antenatal care or specialist obstetric care due to high risk patients .. i have 35 years experience , DipRANZCOG stay current and informed and feel totally alienated

DR HARRY HABER   7/12/2018 12:27:16 PM

The unfortunate fact is general practice has been restricted from public hospital access and obstetric care is now only shared care but not delivery care. This results in midwifes being the care givers . I do not see any change in this policy

Dr Susan Margaret McDonald   7/12/2018 1:12:48 PM

It's the same in Cairns. We are completely marginalised and ignored. Share care is no longer. They always take over the patient unless the patient is experienced and assertive and says no.
We are the first port of call when things go wrong in the community but there is no 2 way conversation. It's a very sad state of affairs.
As we no longer have a Division to bat for us collectively we are isolated and alone.

Juliet Gallagher   7/12/2018 1:54:47 PM

I agree Shared care is just not happening in Sunshine coast and North Brisbane regions like before
Registrars ar e not getting to see antenatal patients as they used to so deskilling is increasingly a problem It is a HUGE loss to the holistic care plan for General practice I am very sad about this change and apprehensive for the future of our women and childrens care

Dr Lisa Meriah Fraser   7/12/2018 5:20:12 PM

i have gone from high rates shared care in ipswich, caring for all my low risk public women until delivery in springfield to none in ingham. i understand what it is to feel like i am deskilling. and when the patient comes in with a problem, i have no idea about their antenatal history.

Dr A Nguyen   12/12/2018 12:33:09 AM

As a ANSC provider and recent new Mum I cannot more strongly see the value in GPSC. Whilst there are some wonderful midwives they just don’t have the training or broad medical knowledge to provide holistic antenatal and postnatal care. I have looked after several women prior to marriage, during family planning, through pregnacy and post partum and subsequent pregnancies and their children. How is it possible to build that relationship in any other means than via GP ANSC

Nicola Pennell   12/12/2018 12:49:06 PM

I have to agree with the above. I was working in Perth were we had a reasonable communication with the hospital and shared care was heavily encouraged due to the clinics being so busy. But now in Newcastle, I have had pregnant women taken out of my care into midwife care simply because they are overweight. The clinics must be so overworked given the high rates of overweight and obesity... Surely we are in a better position to manage overweight women than in a hospital? The women do not like seeing a different person each visit and they lose continuity of care also. I understand not all GP's want to do Shared care (just like not all GP's want shared care for a number of other health problems) but could the hospitals have a list of DipObs or GP's interested in Shared care and refer their women to these GP's? I see one of the roles of GP's as being advocates for their patients, and this is yet another area we need to advocate for.