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At the heart of general practice since 1960

The birth of an idea

Take two obstetric units, nearly two hours drive apart, neither meeting their tariff costs, and redesign a pathway. Answers on a postcard please

http://www.pulsetoday.co.uk/practical-commissioningl

Take two obstetric units, nearly two hours drive apart, neither meeting their tariff costs, and redesign a pathway. Answers on a postcard please.

The story so far

Dr Peter Weaving, a GP in Cumbria, has been involved with GP commissioning since the early days of PBC. The Cumbria Senate, as the consortium is known, was recently chosen to become a first-wave pathfinder and is generally regarded as a trailblazer for its commissioning successes, not least in steering the PCT out of a £50m deficit. Our diarist, however, is under no illusions about the scale of the challenges ahead. Take redesigning maternity services...

Red, occasionally green, columns of figures scroll past my weary eyes. Like a Las Vegas gambler studying the revolving reels of a slot machine I seek the winning line of our financial performance tables that will bring me financial balance at the year end. Not only am I not lucky, I'm not really interested – a GP commissioner is more interested in clinical commissioning of real services for real people than the dry balance sheet of a busy night in A&E. And later we have the main bout – a serious head-to-head event; the first test for our clinical leaders' group with consequences for 300,000 people.

We are considering future arrangements for maternity services across the patch and, if you have a minute to spare, your input would be appreciated. You could perhaps solve a problem that has been the subject of countless reviews – what to do with two smallish (less than five deliveries a day) consultant-led obstetric units under one trust but separated by a blue-light transfer time of one hour 43 minutes and 42 seconds.

Now, as a GP, you will know each of these units of obstetricians needs to be backed up by operating theatres, anaesthetists and paediatricians, even though nine out of 10 of those deliveries will need only a competent midwife to deliver a healthy, bouncing baby.

You will know that women in labour travelling for long periods in ambulances carry measurable and predictable risk of adverse outcome. But as a commissioner you will know that one unit delivering all 3,000 babies would be easier and more cost-effective to staff; it would be a viable training unit for junior staff and, more importantly, be busy enough to maintain consultants' expertise in dealing with complications. You also know most trusts do not meet their costs on the current obstetric tariff and you certainly won't on this split site model.

Can you bridge the gap? Can you say to a mum it is reasonable to travel 40 miles to have her baby? In Finland they travel 200, but do so two weeks before the baby's due. Are there models elsewhere in the UK? No – there are smaller more isolated units, but only delivering 20 or so babies a year, not 1,500. So it looks as if the right answer may be to continue with your two units.

If that is so, how will you reassure yourself of the governance around these units; that they are delivering as competent, safe and experienced care as your larger unit may have provided? Are you going to run a consultant-provided service because it's not busy enough to support junior rotas? What are consultants going to do when there may be 48 hours between interventions?

This is the reality of our brave new world – primary and secondary care clinicians coming together to plan the health service for their population. We are supported but not directed by our management colleagues. So, future GP commissioner, what have you chosen to do?

Dr Peter Weaving

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