Readers' letters - 8 November 2012

The GP contract is flawed but vital

I read the article ‘GP practices’ huge income variation revealed’ with interest. I agree that such a wide variation in income per capita of needs-adjusted populations is just not acceptable, as is the application of payments, which are national policy “but not universally applied”.

‘We have learnt through experience that focusing on fees for service does not deliver the quality outcomes patients seek’

However, taking a potshot at personal medical services contracts is not the answer. Such contracts, though often abused and poorly administered in the scheme’s later waves, offer the flexibility that is now essential to deliver appropriate and tailor-made services fit for the 21st century and meet the needs of local, often atypical populations, while delivering value for money.

Both in primary and secondary care, we have learnt through experience that focusing on fees for service does not necessarily deliver the quality outcomes patients and taxpayers seek. The NHS cannot continue down this road.

We heard this week that PMS will continue to exist, but the scheme will be rebalanced in line with the proposed new general medical services contract. It, too, will focus on improved outcomes for the health of local populations. Because of its flexibility and sensitivity, PMS contracts will be better placed to deliver the healthcare that patients need; a local view of need, determined in collaboration with local populations, not determined nationally by central government.

The GMS contract is currently too blunt an instrument to deliver modern, world-class primary care.

Maggie Marum, independent consultant

Maternity monopoly

Greater Manchester may be congratulating itself on managing the reduction of the number of maternity hospitals from 12 to eight, but in the process it has shuffled around women and midwives like pawns in a game of Monopoly.

It now has an over-provision of expensive maternity units at the expense of home birth and birth centres. In the process, by ignoring the input from mothers and midwives, it has emptied the goodwill coffers of the Community Chest.

‘Women have been calling for a more personal approach to maternity care for years; they want a midwife they know and trust’

How clearly Leila Williams describes the rationale for mergers - a need to pander to obstetric doctors’ training needs; these are amply supplied by women put through the production line that is now the norm for hospital birth. But there is scant regard for a woman’s need to have a known and trusted midwife to encourage and support her towards a normal birth.

We don’t agree that it is the women who are calling for 24/7 consultant care - this has always been an aspiration of the Royal College of Obstetricians and Gynaecologists, with medical opinion being the only evidence proffered in an effort to boost consultant numbers.

If medically luxuriant facilities have better outcomes for women and their babies, the mergers might have been justifiable – but the outcomes are worse. The evidence of the 2011 Birthplace study is that midwifery units and home have far better outcomes for all low risk mothers and for all babies except those of first time mothers. And it is less expensive.

Women have been calling for a more personal approach to maternity care for years; they want a midwife they know and trust. The National Institute for Health and Clinical Excellence also recommends this for antenatal and postnatal care - if not yet for intrapartum care. All midwives want to work in a way that enables them to treat women as individuals, not just ticking the boxes before rushing off to deal with the next one.

All over the country obstetric units have an insatiable appetite for midwives. They pull midwives in from the community without giving time off in lieu, leaving them to cover their community clinics as best they can. Whenever they think they can blame a poor outcome on a midwife, management chews them up and spits them out.

Is it any wonder that staff sickness is on the rise, that midwives are leaving the profession? Mothers and babies suffer the consequences.

The Greater Manchester mergers were indeed premature; the RCOG’s own report, High Quality Health Care, called for the “need to drive care back into the community, with appropriate provision of facilities and professionals with the appropriate skills”. Merging hospitals to create mega baby factories has the opposite effect.

And Leila Williams was curiously silent on the issue of caesarean section rates. Women pay the price of avoidable emergency surgical delivery; all too often, postnatal depression and even post traumatic stress disorder come in the wake of unforeseen surgery. And poor maternal mental health has adverse consequences on child development.

Commissioners should beware of following Greater Manchester’s example. They would do better to travel westwards to Wirral where the One To One midwives are caring for 10 per cent of women and getting excellent results. This is reducing pressure on obstetric units and enabling more women to have a safe, satisfying birth and a gentler transition to motherhood.

Margaret Jowitt, Editor, Midwifery Matters; Ishbel Kargar, retired midwife; Deborah Hughes, research midwife, Cambridge; Grainne Millwood, Royal College of Midwives representative; Association of Radical Midwives, Oxford