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Tuesday, 8 September 2009
Page: 8945


Mr HARTSUYKER (7:00 PM) —On the face of it, there is much to support in the Health Legislation Amendment (Midwives and Nurse Practitioners) Bill 2009 and cognate bills. There is even more to support following the minister’s spectacular backflip on the position of the government in relation to midwives. I shall have more to say on that later. It is very much an example of the government rushing to legislate on issues without paying attention to the detail and without thinking through the consequences of the government’s actions. For the moment, I will say that I welcome the minister’s partial backdown, which will allow the status quo in relation to midwives to continue until 2012.

For many years the Commonwealth has battled with the problems of labour shortages in the health services, particularly in regional Australia. We are familiar with the efforts made to increase the number of training places for doctors and nurses, to encourage the newly qualified to pursue a career in areas where they are most needed, and to attract suitably qualified practitioners from abroad to come to Australia to work. As in many areas of the health service, it is debatable whether we will ever be able to do enough to generate the size of workforce that we need to satisfy an ever-growing demand. Combined with the difficulties of providing costly services in sparsely populated areas, we have the problem of an ageing and therefore more demanding population with rising expectations of what the health service should deliver and new treatments being ever more complex and ever more expensive and requiring ever more highly trained practitioners to deliver.

The 2005 Productivity Commission report drew attention to the fact that there was no single solution to meeting the demand for health services and a multipronged approach was needed, so I welcome the moves contained in these bills to enable midwives and nurse practitioners to make a greater contribution to patient care. The Australian Medical Association and other medical professionals clearly have reservations, but I fully support the principle of enabling other health practitioners to share the load and to help ensure that people throughout Australia receive timely and effective health care.

Experience in the UK suggests that patients were generally satisfied with nurse practitioner consultations and that there were few differences in clinical care and clinical outcomes. Better utilisation of nurse practitioners could help to ease the load on our overstretched GP workforce. If we are running our GPs into the ground, we cannot expect them to be able to maintain the highest quality services for our communities, when they are just overworked. Patients would be treated more quickly, chronic conditions would be better supervised and health resources would be used to maximum benefit if we were to maximise the capabilities of our entire medical workforce. It is all about providing the appropriate level of care with the appropriate level of competency and the appropriate level of supervision. Why should a patient have to wait to see a doctor when their ailment or complaint could be quickly and effectively treated by a nurse or nurse practitioner, suitably supervised and under the watchful eye of GPs?

The principle of this legislation is good but, as with so much else that the government produces, when it comes to the detail it falls down. Let us look for a moment at the government’s mercifully short track record on getting the detail right—or, unfortunately, getting the detail completely wrong. When we had the global financial crisis, we needed a bank guarantee scheme. The air was thick with warnings that the scheme should not be unlimited, but the government, driven by its compulsion to be seen to be doing something and the need to grab the day’s headlines, went for an unlimited bank guarantee, and the result was chaos.

What about the changes to Youth Allowance? The lack of attention to detail threatened to derail the financial plans of many students in their gap year. What about the tax bonuses? Too many people thought they were going to receive a payment from the government when in fact, when you looked at the fine print, they missed out. What about computers in schools? What about flood relief payments? All too often, people were denied the assistance they needed and their rightful entitlements because the government schemes were not properly thought through. There were the issues of petrol prices and the failed Fuelwatch scheme. There was the failed GroceryWatch scheme. It was an election promise to put downward pressure on grocery and petrol prices, and the only responses to that were two failed schemes by this government.

The health service was going to be fixed by 30 June 2009 or the government was going to take it over. The government was going to step in. The buck stopped with the Prime Minister on health. The Prime Minister made a very clear, very unequivocal promise that if it was not corrected by 30 June 2009 he would step in and fill the gap. Sadly, it has not been fixed. The health service still faces severe challenges, and the government is rapidly backing away from its promise that the buck stopped with the federal government in relation to health services.

As I said earlier, the issue of extending the role of midwives and nurse practitioners is all about providing the appropriate level of care with the appropriate level of competency and the appropriate level of supervision. This is one of the areas where the legislation falls down. The coalition believes that GPs will continue to be the foundation of primary health care. They are called ‘general’ practitioners because their training enables them to properly assess the whole range of ailments and to recommend the most suitable next step for treatment. Of course, for the sake of patients and GPs, we should be trying to ease their burden. Transferring some of their work to midwives and nurse practitioners is one way of making sure that we maximise the output and clinical outcomes from our workforce.

While I have the utmost confidence in the professional judgment of medical staff to recognise the limits of their own training in diagnosis and treatment, what we need from the government is some idea—indeed, any idea—of the arrangements that will make these measures work. Who will decide whether a patient sees a nurse or a doctor—the GP’s receptionist? What level of supervision will the GP be expected to provide? How can that be provided given the GP’s own workload? Unless these details are considered, we could be moving toward a two-tier health service where a patient agrees to be seen by a nurse simply because it is quicker and more convenient. Surely there needs to be some clinical input at a very early stage to make all of this work, but the government has given us no guidance in relation to these crucial matters.

Before turning to the second area in which this legislation fails, the issue of midwives and homebirths, I will briefly mention costs. No one likes putting a price on health care but, as demand and costs rise, we have to do just that. In mid-2007, the coalition was spending some $6.4 billion a year on the Pharmaceutical Benefits Scheme and $11.7 billion on the MBS at a time when we were running a surplus. Those figures will inevitably grow at a time when the government is in the process of racking up a debt of over $300 billion. Against that background we need more clarity on what the government’s proposals are in relation to costs.

The proposals will give nurse practitioners the ability to refer patients to specialists. Currently, GPs only refer a small proportion of their patients to specialists. It seems reasonable to assume that referrals will increase but the proposals give no clue as to the effect on specialists’ waiting lists, how this might fit into a collaborative model or the impact on costs. Neither is there any detail of the workings or consequences of the new ability of midwives and nurse practitioners to order pathology and diagnostic services with a Medicare rebate. With the government strangely reluctant to release its economic modelling on this and other matters, one is left with the conclusion that they have something to hide or that they have nothing to hide because once again they have rushed out with another policy decision without fully examining the cost, without having done their homework.

I now turn to the failure in this legislation which has caused the greatest concern and the greatest controversy: that of midwives’ professional indemnity and homebirths. Again, we have a situation where the government has displayed a lack of attention to detail. Because of the interaction between these bills and the national registration and accreditation scheme, from July next year midwives would have been prevented from assisting at homebirths, effectively removing the option of women giving birth in their own home.

I acknowledge the great work done by the Coffs Coast Maternity Action Group in my electorate in defending the mother’s right to choose, and I know that they and many other groups around the country will be welcoming this humiliating—but welcome—backflip by the minister, albeit a temporary reprieve, until 2012. It is hard to tell whether her initial position of banning midwives from homebirths was an intended consequence or an unintended consequence of this legislation. Given that their brief legislative record is littered with unintended and unwanted consequences, it seems more likely that this was the result of the government’s habitual bungling.

The fact of the matter was that, under the new registration scheme, practitioners would have been required to have suitable professional indemnity insurance. While the government proposes to provide insurance to midwives in a clinical setting, it would not have extended to cover homebirths. Furthermore, the exposure draft of the Health Practitioner Regulation National Law 2009 (Bill B) states that an individual who practises as a midwife without indemnity insurance and is therefore unregistered may be subject to a maximum fine of $30,000, effectively making the choice of a homebirth illegal. It is absolutely astounding. It is highly unlikely that it would be practicable or viable for a midwife to arrange her own insurance to cover for homebirths.

From July next year, having a baby at home would have ceased to be an option. It is true that only a small proportion of mothers choose to have their baby at home. However, with the benefit of medical advice it should surely be the right of every mother to give birth in their own home rather than in a hospital. Indeed, given the parlous state of many of our hospitals, and the current pressures on staff—both matters that the government has pledged to fix—one would argue that mothers should be encouraged to give birth at home if that is their choice. By removing the midwife, the government was removing the right to choose for the mother.

However strongly they may feel that home is the right place to give birth, few mothers would feel it was in the best interests of themselves or their babies to give birth at home without a midwife. There was also the worrying aspect that policy on health care was being driven by the matter of insurance. If the government believes that homebirths are undesirable from a medical point of view, it should have said so. It appears that the government now believes, as we do, that, subject to medical advice, homebirths are a suitable option for many mothers.

It has adopted basically the position that has been proffered by the coalition. We certainly welcome that backflip that has delivered the status quo, at least for the time being. This decision has been very much a subject of some controversy. Certainly, people within my electorate have expressed very strong views about this. But it has been an embarrassing climbdown for the minister, an embarrassing backflip, but welcome all the same.

We still have to wait and see what happens after 2012 and what the situation will be in relation to the choice for mothers after that date. But we certainly, as I said, welcome the change that has been made. In my area we have a range of smaller hospitals that see their level of services constantly being downgraded. The maternity unit at Bellingen hospital has been the subject of a great deal of attention as to whether services will continue there. I know many people in the Bellinger valley would welcome the opportunity to continue having the option of homebirths for their children.

We do welcome the change of heart by the minister. Unfortunately it has caused a great deal of anguish amongst many people in my community who wish to maintain the option of homebirths. We are concerned about what the situation will be after 2012 but certainly the changes by the government have been welcomed.