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A HSE decision to withhold payments to GPs poses a serious threat to the delivery of antenatal care.
The history of the Mother and Child Scheme dates back to the health reforms of 1943, and includes a series of titanic battles between bishops, doctors, and politicians before finally being implemented in 1953.
The scheme has endured until the present day (and is now called the Maternity and Infant Care Scheme). Contracted GPs provide care for pregnant women and new-born babies from the time of diagnosis of pregnancy until six weeks postnatal. The current paymaster is the Primary Care Reimbursement Services (PCRS). GPs are paid for up to nine visits for a first time mother and 10 visits for subsequent pregnancies. These visits include two consultations at two and six weeks post-delivery. Consultations for illnesses that are coincidental and not related to pregnancy will not be paid, but five additional consultations per pregnancy can be claimed by the GP for chronic diseases that adversely affect pregnancy and require additional monitoring, such as diabetes and hypertension.
Payments for pregnancy consultations are much less than the standard private consultation fee and must be claimed either manually once all care has been provided, or online following each visit.
It is well known that good antenatal care reduces maternal and infant mortality and morbidity. In Ireland today, one-in-172 babies born after 24 weeks gestation are stillborn or die within a week of birth. Dr Nóirín Russell, Consultant Obstetrician and Gynaecologist, Cork University Maternity Hospital, speaking on an ICGP webinar earlier this year, emphasised the contribution that GPs make to antenatal care.
“Simple screening is life-saving squared,” she said, emphasising that providing good maternity care is a joint project between hospital and community. Monitoring blood pressure, enquiring about foetal movements, checking for bacteriuria and glycosuria are simple but effective pregnancy screening measures. “Doing these things right will certainly save babies’ lives and may save some mothers’ lives,” Dr Russell said. Alongside this, GPs remain alert to all the other morbidities that can affect pregnancy such as mental health problems, obesity, venous thromboembolic risk factors, asthma, and thyroid disease, providing intervention or referral as necessary.
Antenatal consultations also include guidance on breastfeeding and vaccination. GP antenatal care may be low
technology, but it is important, complex and effective, and is valued by women and healthcare professionals alike.
It does not make sense that there appears to be a move to undermine and hamper the delivery of this care by the PCRS. Since April 2021, in our practice, claims for additional payments for hypertension, gestational diabetes, and urinary tract infections have been consistently rejected for payment and I am told that I am not the only GP who has had this experience.
My staff and I have made numerous phone calls and sent repeated emails to the PCRS, but to no avail. Our phone calls have been answered by a polite and helpful person who has explained that the decision on payment for each claim is made by the Chief Medical Officer(s). It is not possible for us to contact these officers directly. It is not possible to find out who exactly has rejected the payment. We were advised to send an email to the individual who had answered the phone and she would send it on to the relevant personnel. She reassured us we would receive a prompt reply. A month and a few telephone calls later, we have still not heard anything.
The decision to withhold payments to GPs poses a serious threat to the delivery of antenatal care. GPs cannot continue to provide care that is not reimbursed. The World Health Organisation have designated the detection of asymptomatic bacteriuria in pregnant women as one of the 10 most cost-effective screening interventions worldwide. Detecting an asymptomatic urinary tract infection can prevent perinatal death and septic shock in a mother.
GPs provide antenatal care by completing small tasks consistently and well; repeatedly dipping urines, while assessing mental health, checking blood pressure, advising on vaccines, breastfeeding, and offering other brief interventions that have long-lasting beneficial effects. We sign a contract, maintain our medical insurance, and professional competence. We do this quietly, without fanfare and we have a right to expect payment.
The value of this service is obviously not appreciated by the medical officers in the PCRS. Pregnant women may not realise that reducing their access to this care puts them at significant increased risk of morbidity and mortality, but I do, and I would rather cease providing antenatal care than provide half a service.
GPs are best placed to uncover risk factors for stillbirth and maternal morbidity, but we can only do this if we are allowed to do so and paid for our efforts. The Maternity and Infant Care Scheme is not perfect, but it is all we have and it was hard won. We owe it to those who fought for it to preserve and expand it rather than allowing it to be destroyed.