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Monday, 7 September 2009
Page: 8726


Mr CRAIG THOMSON (7:42 PM) —I rise to support the Health Legislation Amendment (Midwives and Nurse Practitioners) Bill 2009, the Midwife Professional Indemnity (Commonwealth Contribution) Scheme Bill 2009 and the Midwife Professional Indemnity (Run-off Cover Support Payment) Bill 2009. The purpose of the Health Legislation Amendment (Midwives and Nurse Practitioners) Bill 2009 is to amend the Health Insurance Act 1973 and the National Health Act 1953. This amendment will support the inclusion of nurse practitioners and appropriately qualified and experienced midwives under the Medicare Benefits Schedule, the MBS, and the Pharmaceutical Benefits Scheme, the PBS, in line with the 2009-10 budget measures. We have heard much in this debate about the coalition’s commitment to and undying respect for midwives and so forth, yet these aspects of the bill are issues that could have been addressed in the last 10 or 11 years but the coalition chose not to. It is worth pointing out that, since 2001, midwives in private practice have in fact been without indemnity insurance. Part of the purpose of these bills is to look at making a better situation for both the consumer and the midwives who are practising.

The midwives and nurse practitioners bill will enable these health professionals to request appropriate diagnostic imaging and pathology services for which Medicare benefits may be paid and prescribe certain medicines under the PBS. The 2009-10 budget measures also provide for the creation of new Medicare items and referrals under the MBS from these health professionals to specialists and consultant physicians. MBS and PBS benefits are to be available from 1 November 2010.

The Midwife Professional Indemnity (Commonwealth Contribution) Scheme Bill 2009 and the associated Midwife Professional Indemnity (Run-off Cover Support Payment) Bill 2009 will support the new MBS and PBS arrangements by enabling the establishment of a government-supported professional indemnity scheme for eligible midwives. The Australian government is proud to be implementing historic reforms in maternity care which recognise the skills of our highly trained midwives and provide more choice for Australian women while maintaining Australia’s strong record of safe, high-quality maternity services.

The report Improving maternity services in Australia: the report of the Maternity Services Review highlighted the complex nature of maternity services, which involve a mix of Commonwealth, state and territory, and private arrangements. It was developed following consultation with a broad range of stakeholders, including individuals, health professionals, industry groups, researchers, professional organisations and national peak bodies. The report made a number of recommendations which focused on the need to improve the maternal and perinatal outcomes for Indigenous and rural Australians, improve choices available to pregnant women, increase access to high-quality maternity services and provide support for the maternity services workforce.

The government responded to the report with a $120.5 million package to provide access for midwives to the Medicare Benefits Schedule and the Pharmaceutical Benefits Scheme medicines and a government-supported professional indemnity insurance scheme for eligible midwives. On 24 June 2009 the health minister introduced legislation to facilitate these new arrangements. These arrangements will be available to appropriately qualified and experienced midwives working in collaboration with obstetricians and health facilities as recommended by the report and will not, at this stage, cover homebirths.

Let us look first at how these changes will affect nurse practitioners, and then I will come back to homebirths and the whole issue that has probably dominated most of the debate on these pieces of legislation. Nurse practitioners can already provide health-care services and prescribe medications in a majority of jurisdictions. However, the midwives and nurse practitioners legislation will enable their clients to access MBS- and PBS-subsidised services and medication. There are currently around 350 qualified nurse practitioners in Australia, generally working in public hospitals. Initially, around 50 nurse practitioners are expected to access the MBS and PBS for their clients in certain private and community settings, particularly in primary care and rural areas, from November 2010.

For midwives to be eligible to participate in the new arrangements they will need to meet advanced practice requirements and have collaborative arrangements with doctors. These requirements and collaborative arrangements are being developed in consultation with midwives, doctors and other stakeholders. The reform initiative supported by this legislation will allow for incremental reform within a strong framework of quality and safety. It is expected that around 700 eligible midwives will be participating in this measure over the next four years.

The government understands the concerns in the community about registration and professional indemnity insurance and how this affects the involvement of midwives in homebirths. The three bills before the House expand Commonwealth support for midwives and nurse practitioners in our community. They improve choice and extend Commonwealth funding for a range of midwife and nurse practitioner services for the first time ever, including providing antenatal care in the community and attending births in clinical settings. None of these bills makes homebirth unlawful.

The separate draft bill for the national registration and accreditation scheme for health professionals currently carries a proposal that will require health professionals from 10 professions covered to carry insurance as a condition of registration. The draft bill was prepared for all jurisdictions via a COAG agreement and is not yet before any parliament. Our government has been concerned about the unintended consequences of this provision on homebirth. That is why I am so pleased that last Friday, on 4 September, the Minister for Health and Ageing was able to achieve agreement from all health ministers around the country to a transitional clause in the current draft national registration and accreditation scheme legislation. This has been achieved with all governments working together to obtain an outcome that is progressive for the sector but will not make homebirths illegal.

The decision on Friday was significant, a very important breakthrough in the national registration and accreditation scheme. The registration and accreditation for 10 professions is about lifting standards and ensuring that people are registered and accredited and that to be registered they have to be insured. This presented, of course, a particular problem for homebirthing midwives, where no insurance product is currently available and where the Commonwealth’s budget package was not intended to cover these arrangements. But the states, territories and the Commonwealth have now agreed to a two-year exemption for homebirthing midwives who are acting, of course, not within the state hospital system but in the private sector.

There will be a number of conditions and requirements attached to that exemption, which include that a homebirthing midwife must disclose to a mother who is interested in having a homebirth that they will not be insured for that procedure and make sure that people are able to make an informed choice about undertaking a homebirth. The government will ask homebirthing midwives to report each homebirth. There is currently not any good data across the country of how many homebirths actually occur. Independent midwives are not currently required to notify state and territory authorities or hospitals, and nor have they been asked to. We will require, however, participation in quality and safety frameworks—for example, reporting the results of homebirthing and incidents that are related to it.

The government wants this work to be done in a collaborative way by way of a peer review process. That consultation process will be overseen by Victoria, which has chaired the national registration and accreditation process. The national Nursing and Midwifery Board will provide advice and protocols for homebirthing outside the publicly funded and auspices services. Privately practising midwives—some of whom currently provide homebirthing services but do it as part of their employment, either with the state or with a private practising obstetrician—would not be affected by these changes as their insurance is already covered through their employment status. Clearly this arrangement will not apply in jurisdictions where there is no lawful homebirthing occurring.

This two-year exemption allows plenty more time for those protocols to be established and to be worked on. In the meantime, the arrangements agreed to last Friday ensure that homebirthing midwives can lawfully continue to provide the services in the jurisdictions had currently allow that. They will continue to be uninsured, as they currently are. The government will be collecting more data on homebirthing and there will be a process to further work through these protocols that would either bring more homebirthing services into our public system or potentially open the way in the future for an insurance product to be extended to cover them. Homebirthing programs operate in a number of state and territory systems with participating midwives coming under the insurance cover of the public health system. Midwives who provide maternity services in an independent private capacity, including assisting with homebirths, currently do so without indemnity cover as there are no products currently commercially available.

I have met on a number of occasions with my local representatives of the Maternity Coalition. In fact, I first attended a meeting at a park in Long Jetty some three months ago where these concerns were raised. They are legitimate concerns about making sure that homebirthing is there as a choice for women. While homebirthing has been very much in the minority—in fact, much less than one per cent of pregnant women choose to give birth at home in Australia—it has nonetheless been at the forefront of innovation in relation to birthing. Water births and the like were products of homebirths. And I think everyone in this place must be a little concerned at the extremely high rates of caesarean operations that we have in this country, well over 30 per cent, when the World Health Organisation talks about 15 per cent being around what would naturally occur in most communities. On the Central Coast that problem is even greater, with Gosford private hospital having caesarean rates in excess of 50 per cent and Gosford public hospital having caesarean rates in excess of 40 per cent. So you can understand that women on the Central Coast do want to have options that involve midwives so that a caesarean is much less likely in those circumstances.

In March last year the Council of Australian Governments signed an intergovernmental agreement to implement a single indemnity scheme by 1 July 2010. The scheme will initially cover 10 health professions: medicine, nursing, midwifery, pharmacy, physiotherapy, podiatry, osteopathy, chiropractic, optometry, dental care—which includes dentists, dental therapists, dental hygienists and dental prosthesists—and psychologists. The current proposal under the draft legislation for the scheme requires professional indemnity insurance as a mandatory condition of registration for all health professionals, including midwives. This is an important part of raising standards and providing public protection for patients and consumers. The Australian government is committed to building on its 2009-10 budget maternity services reform package by working with the states and territories, and with key stakeholders, to develop a national maternity services plan to ensure coordination of maternity services across Australia.

The member for Flinders spoke about his personal experiences in relation to midwifery. And I would like to share with the House some of mine too. Seven weeks ago I was at the birth of my daughter, Matilda Arnold Thomson, who is seven weeks old today. We chose in our circumstances to have the delivery take place at Wyong Hospital but at the birthing unit, which is run by midwives, at Wyong Hospital. There are no obstetricians at Wyong Hospital. You essentially are under the care of a midwife from the time you know about the pregnancy and they are with you through the whole pregnancy. When it is time to deliver, you go to the hospital to a room that looks very much like a room would at home with the big bath and a bed and your midwife is there with you. You do not have the option of epidurals, you do not have an obstetrician there, but of course this is carefully screened to make sure that it is aimed at women who will not have difficulties with the delivery of their babies. Should something go wrong or not go according to plan, you are immediately whisked 10 minutes down the highway to Gosford Hospital, where there are obstetricians and medical practitioners available.

The reason that I am very much in favour of making sure that homebirths are an option is the terrific experience that we had with a first-class midwife, Val Paynter. She was in fact midwife of the year in New South Wales last year, and my experience with her leaves me in no doubt as to why she achieved that recognition. The experience we had could just as easily have happened at home at Bateau Bay, which is probably three or four minutes closer to Gosford Hospital had something gone wrong. What was essential was that we had a registered midwife who had indemnity insurance because she worked through the hospital, and we had the choice of this method of birth.

The only reason that the birthing unit at Wyong Hospital is open is that it adopted a new model and went to a midwife led birthing unit; otherwise, the inability to attract an obstetrician to one of the most beautiful parts of Australia, the Central Coast, would have meant that this unit would have closed down. So the choice that was made by the hospital to adopt this model was probably one that was done out of practicality, but the result has been a terrific one for the citizens of Wyong and the surrounding areas. I very much want to place on record my thanks to the hospital and to the midwives who did such a magnificent job and do a magnificent job every day there.

What this shows is that there are many different models and many different choices available to women at the moment. The announcement that the minister made on Friday of last week means that the option of homebirth is still an option that is there. But in all of these considerations and in all of these choices we also have to be mindful of the safety of the pregnant woman and the safety of the child who is going to be delivered, and that is why this legislation goes to the issues of accreditation and registration and the issues of making sure that the standards are raised and are uniform across the country, and also importantly goes to the issue of indemnity insurance so that there is that protection there for the consumer as well.

This is a balanced package of legislation before this place, a package that meets the aims of improving midwifery, of placing a greater emphasis on it in our birthing models as well as balancing the issues of safety and accreditation. These are important pieces of legislation that do not outlaw homebirth, that make sure that there are schemes in place and the opportunity over the next two years to gather proper data on the Australian experience of homebirth and to see where that brings us in the evolving issues of maternity and birthing schemes operating around Australia. I commend these bills to the House as very important bills.