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Tuesday, 8 September 2009
Page: 8933


Mr BILLSON (6:05 PM) —I rise to talk about this package of three bills. For those listening, there are actually three pieces of legislation being discussed together before the chamber. There is, of course, the one that is most topical, which many have heard about, involving midwives and nurse practitioners—the Health Legislation Amendment (Midwives and Nurse Practitioners) Bill 2009—but there is also legislation relating to the midwife professional indemnity Commonwealth contribution scheme and the midwife professional indemnity run-off cover support payment scheme.

Essentially these three bills have separate aims. The first one is to amend the health legislation to provide for eligible nurse practitioners and midwives to request diagnostic imaging and pathology services under Medicare arrangements and to prescribe a limited range of medicines under the Pharmaceutical Benefits Scheme. The second bill, theMidwife Professional Indemnity (Commonwealth Contribution) Scheme Bill 2009, which is linked to the first bill, is to provide for a Commonwealth scheme with assistance for midwives in accessing indemnity for claims arising from their professional activities in a collaborative clinical setting. The third bill, the Midwife Professional Indemnity (Run-off Cover Support Payment) Bill 2009, imposes a tax on midwives’ professional indemnity insurance to cover run-on cover for midwives who have ceased practising. That is the package of bills before the House.

The first bill, in extending MBS and PBS access to nurse practitioners, is potentially a very valuable mechanism for a range of objectives. First of all, there are skills shortages in the medical field and doctor shortages, particularly in outer metropolitan areas and regional and rural areas. This is a trend that was started, in terms of expanding the role of nurse practitioners, under the Howard government. It is good to see that the Labor government is carrying on that tradition established by the Howard government. It reminded me a bit of the election campaign, where the Howard government seemed to make its views and election policies known and then those were echoed by the then Labor opposition. It is good to see that that practice is continuing now that Labor is in government!

The provision and coordination of patient care by medical practitioners is a really central issue for all of us concerned about good health outcomes. Naturally this legislation has safeguards about who can exercise these expanded responsibilities. They are all designed within a framework aimed at protecting patients, their care and welfare. Midwives are included in the measure as part of the government’s response to the maternity services review and also a considerable lobbying effort by midwives and a number of patients of midwives, who have been very positive and very upbeat in describing the services that they have accessed—particularly where they have been looking for a low-intervention pregnancy—and the important role midwives play not only in those low-intervention pregnancies but also in pregnancies in general. The Howard government was very interested in pursuing this pathway. I recall, quite vividly, hosting a meeting in my office with then health minister Tony Abbott to discuss the mechanics of this kind of idea. It is good to see that that momentum created by the previous government is being carried on here.

There is a significant amount of money attached to this, and that is appropriate. It has been characterised in a number of different ways in this place. Some of that funding is actually to put the machinery in place to enable the PBS and MBS access. It has been characterised differently by some people, as some direct change in services or money going to maternity. Some of it is going to those activities but there is also quite an amount going to putting the infrastructure in place to enable that expanded access to MBS and PBS services by nurse practitioners. So it is encouraging that we are seeing a greater role for nurse practitioners and midwives.

I particularly want to point out some misunderstandings about the evidence. I think the body of evidence is absolutely clear that having nurses, nurse practitioners and midwives operating in a collaborative environment—recognising skills, qualification, experience and the input of other health professionals—delivers better health outcomes. That is why I am very keen to see an expansion of the role of midwives. I believe also that there are clear efficiency benefits. It seems to me that, in a highly skilled workforce, including a range of clinicians and medical practitioners, nurses are highly skilled and should be able to operate at their highest and best use. That is my understanding of efficiency—where people with those competencies and experience can fully exercise them. I am pleased to see that these measures go some way towards ensuring that that full contribution, using that full set of skills, that nurse practitioners and midwives can make can actually be made and delivered to the benefit of patients in a collaborative health system.

This is sometimes characterised as a response to workforce issues. Again, something that the Howard government pursued was a greater role for practice nurses and greater support for nursing generally. We had plans and took action to address the issues behind why nurses were not working in their profession. That not only included a range of issues around clinical support and opportunities but also related to poor hospital management, in some cases, where nurses were dissatisfied with the working environment and looking for an opportunity to fully exercise their skills. The Howard government had a plan and had an agenda for that. It is sad that some of those hospital management reforms, which would have increased the likelihood of ex-nurses returning to a career in nursing, have not been pursued quite as vigorously as I think they should have been. There is also an issue around greater support for nurses along with incentives to bring nurses back into the workforce. Again, that was an initiative implemented by the Howard government and carried forward by this Labor government.

I think it is also important to recognise the service enhancement potential of fully utilising the skill set of nurses, nurse practitioners and midwives. This is not solely about, as some would say, an alternative service delivery model where somehow a nurse may displace the activities of other medical specialists; it is actually about what nurses can bring to the task. This is about the way in which that skill set can work collaboratively in primary health care and the important collaboration with GPs and other doctors to have coordinated clinical support arrangements for better health outcomes.

I think the thing that struck me most in looking at this legislation was that it is all well and good to provide enhanced nursing access to the MBS and to the PBS but what I would have liked to have seen is some more action to enhance the availability of nurses. I am mindful of a very positive commitment the coalition made that, had the Howard government continued, we would have seen, for the first time, funding available for practice nurses to visit older Australians—veterans, war widows and widowers—in their home. You can imagine how enthusiastic I was, as the then Minister for Veterans Affairs, about that measure. I recognised that having the practice nurses undertake about 800,000 home visits over a four-year period would have made an enormous positive impact on the wellness and health care of that group in our community—many of whom may have found it difficult to visit their GP; many of whom may not have reflected on their wellness; and many of whom may not have been guided and given the pastoral care of a practice nurse visit to access wellness, health improvement and medical services to make sure that their quality of life was optimised. That was a great policy initiative. It is not something that the Rudd Labor government appears to have even addressed. If you believe, as I do, that nurse practitioners have considerable talents and skills to offer then let us not only expand their scope through measures such as this but also actually improve the availability of that through measures such as those proposed by the coalition prior to the last election.

Who knows what scope there may be to carry forward that kind of idea when the next election comes around. The way the budget is being managed and the extraordinary spending spree that federal Labor has gone on might mean very little scope for service enhancement initiatives such as the one that the coalition advocated prior to the last election. But let me just say that is an example of nurse practitioners being not only able to undertake a wider range of activities to support wellness and health services but also having the resources to go out and deliver that capability to a very deserving group of Australians for whom access to an in-clinic visit may have been difficult. So I put on the record an acknowledgement that that kind of service enhancement does not seem to be on this Labor government’s radar screen, when I would have thought that, if there were resources around, that would have been a priority. But, as I said, who knows what resources may be available once the Labor spending spree takes hold and very limited discretionary expenditure is available to benefit the Australian people. I think, though, that Labor should continue to follow that tradition of picking up the coalition’s lead, just as we saw with attracting former nurses back into the workforce with subsidies and recognising and expanding the role of practice nurses. I think that habit of following what the coalition is doing and proposing is something that Labor should reacquaint itself with.

The Midwife Professional Indemnity (Commonwealth Contribution) Scheme Bill 2009 and the Midwife Professional Indemnity (Run-off Cover Support Payment) Bill 2009 have caused quite a lot of interest in my electorate. It has been personally interesting to me as I join with my family to celebrate the 21st birthday of Isabella. It is 21 days that she has been on this planet. I pay great tribute to her mum, Kate, for her wonderful work. I have seen very recently and close at hand the work of midwives and I admire them greatly. At Andy Griffiths’ practice, a highly respected obstetrician on the Mornington Peninsula, the midwife, Kay—if not Andy’s foreman then certainly his concierge—makes sure Andy does all he needs to do. Then there is the remarkable team at the Bays Hospital in Mornington and the midwifery unit there—a remarkable group of dedicated professionals providing outstanding care. We thank them for their attentiveness.

One of the reasons I raise that recent experience is that it reminds me of how the care that is available to support the bringing of a child into the world is very much related to the situation, the assessment of risk and the medical circumstances and conditions which people face. In the case of my beautiful and extraordinarily talented wife, Kate, her blood group was rather mysterious. Monitoring her circumstance and making sure her blood type did not mix with Isabella’s was a very crucial task that required a high degree of monitoring, supervision, pathology testing and the like. But all of that went very well and we are very fortunate for it.

That is not everybody’s story though. There are in Australia, including in the Dunkley community, numbers of women preferring a very low-interventionist model or even a homebirth. That is a choice that I being a Liberal, with my side of politics believing in personal choice, believe we should facilitate. It is not a choice without serious considerations though. The fact that we are talking about professional medical indemnity and the like illustrates that it is a choice not without some risk, but those risks can be measured and evaluated and a low-interventionist homebirth pathway is entirely suitable for many women who choose that option.

One of the things that has activated the Dunkley community is the way in which these bills conspire to actually make homebirth illegal. The legislation does not say it is illegal; it just says that if you want to be a practising midwife there are certain conditions. One of those conditions involves professional indemnity insurance. If you do not have that then you will be fined. So if the health minister wants to challenge the characterisation of this legislation as making homebirth illegal, let us certainly say it makes homebirth unlawful, if that is more comforting to her. That is what has caused such outrage. The current arrangement of private practitioners providing midwifery services in the home as something that is undertaken between families, the mother and the medical practitioner, who is the midwife, is something that will be shut off by these bills.

This has caused great outrage. I know of a number of people from the Dunkley electorate who made the journey to Canberra. They got to feel the chill of a cold Canberra morning but did so because they feel strongly about this. I just want to put on the record some of those views. I will just pick a couple out. Meredith from Frankston conveyed to me:

I was upset to hear that Minister Nicola Roxon may take the advice of some ‘ill-informed others’ and make it very difficult in the future for a woman to choose a homebirth. The fact that women may not have the right to choose where they birth bothers me greatly. This unfortunately will make the normal and natural process of birth a mechanical and ‘risky’ one, not to mention the strain on the over stretched hospital system.

Meredith went on to say:

Healthy informed women should be able to birth at home, where they feel safe, nurtured and relaxed.

She went on to describe the advantages of that experience.

Other examples that were brought to my attention included one from Rita from Mount Eliza, who described her first birth in a clinical hospital setting and how through a process of further research and discussion she chose a homebirth for her second child. She said:

Needless to say, after much investigating, talking and reading I opted for a homebirth with my next pregnancy. I had continuous midwife care throughout the pregnancy and birth, and our baby was born calmly and joyfully at home. It was a far cry from the previous scenario. I felt comforted and empowered by my/our decision and I feel our baby was far better off with this start in life.

We also heard about other experiences. I will point to the insights shared with me by Kimberlie Furness. Kimberlie, who I have known for a very long time, conveyed to me her distress at the measures the health minister was putting in place—in her eyes, making a midwife-centred birth an option not available to her.

She contrasted the atmosphere and environment in Australia with what occurs in the UK, where low-intervention birthing, midwife-centred birthing and homebirthing are far more common. She conveyed to me that a recent study in the Netherlands, where one-third of women choose the homebirth option, found, in comparing home and hospital births, that there was no difference in death rates of either mothers or babies in 530,000 births. She was very keen to emphasise that, from a funding perspective, in most cases homebirth makes sense as it is so much cheaper, involving fewer costly drugs and less surgery and intervention. She said:

It is unfortunate that currently only 1% of the birthing population choose this option, perhaps through lack of information and education about the choices available and the safety record …

The point that Kimberlie was making is that if this is the choice of women who are well-informed about their own health and the circumstances of their birth why is it not supported? Janelle in Balnarring wrote of her experiences and said that ‘a medical model of care’ that medicalises birth is not for everybody. She too called on me to act to make sure that the choice of a midwife-centred, low-intervention homebirth is available.

In responding to this kind of concern raised by the community, I know that the announcement made by the Labor government is viewed by the women who have been in touch with me—many of whom attended the rally here on Monday—as of no comfort whatsoever. All it is is a stay of execution for a birthing option that they are attracted to and that should continue to be facilitated in our country. They saw the announcement from Minister Roxon as nothing more than political procrastination.

I would characterise it as one of the most perfect backflips we have seen. In politics, backflips are often used to characterise a change of mind or change of heart. But when you think about it, when someone does a backflip they actually end up facing the same direction. This was truly a backflip in that we had the fanfare and the spectacle and all the activity, some delay in the date from which homebirth will not be lawful, but essentially absolutely nothing has changed. We had much movement, much excitement and a lot of ‘ooh-aahing’ from those on the Labor Party side, who were trying to make it sound like something had changed, but nothing has changed except that the end date for homebirthing as a lawful and safe option for women will be two years later than the Rudd Labor government originally planned.

The coalition has argued that there needs to be some genuine action in examining what the pathway forward should look like. The coalition will be moving amendments that recognise that a full and informed debate requires the minister to table the actuarial modelling that she points to as giving rise to an inability to provide professional indemnity for midwives providing birthing services outside a clinical setting. We need a full and informed debate about a review into the provision of medical indemnity insurance and a canvassing of what options there may be—whether there can be a pooling of risk and a coordinated pooling of practitioners operating outside a clinical setting and whether there is some scope, recognising the savings to the taxpayer, for the government to facilitate medical cover. We do not know because we do not know what the data is. We call on the minister to release the data. Above all, we should always have regard for the wellbeing of the mother and child so they are not put at risk. That framework might require a birthing plan—(Time expired)