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Tuesday, 10 December 2002
Page: 7587

Senator LEES (5:18 PM) —I want to place on record my disappointment in the Medical Indemnity Bill 2002 and related bills, their narrow scope and what they highlight about the vested interests in our health system. They should in fact be renamed the `doctor indemnity bills', as the only section of the medical work force that they actually deal with is doctors. I do not deny that professional indemnity insurance for doctors is a very important issue, and that is why this chamber will no doubt pass these bills today. However, what concerns me is a wide range of other health professionals who simply have not been considered by the government or, if considered, the whole thing has been determined to be too difficult and has been put in the too-hard basket.

I note that on 28 March this year the government announced that it would provide a short-term guarantee of up to $35 million to United Medical Protection and Australasian Medical Insurance Ltd, UMP-AMIL—the insurer of about 60 per cent of Australia's doctors. Some $35 million was very quickly offered to sort out this problem. Remember that figure; I will come back to it later.

The current package of bills being debated by the chamber gives effect to the government's policy announced on 23 October this year. The announcement included an extension of the guarantee to UMP-AMIL to the end of next year. It involves subsidising the insurance premiums of obstetricians, neurosurgeons and GPs performing procedures. It is a scheme to meet 50 per cent of the cost of claims of payments greater than $2 million. It involves funding of the incurred but not reported liabilities, the IBNRs, by those medical defence organisations. It also includes a levy, over an extended period, to recoup the cost of funding these liabilities for members of the relevant MDOs.

I am pleased to note that the Australian Competition and Consumer Commission will now monitor medical indemnity insurance premiums to determine for us whether or not what is being charged is justified, and that is certainly positive. But what is all of this going to cost? It seems that it will cost around $246.5 million over four years. That is what the government has allocated in the mid-year review. As I stated earlier, I do not deny the need for the government to act in this area. However, I want to know why—and the midwives and parents, young mothers-to-be in particular, want to know why—this government has leapt to the aid of doctors but has not been prepared to look at the problems faced by other health professionals.

Prior to the withdrawal of insurance for midwives last year, there were about 150 midwives, all women, practising independently in this area—that is, those practising outside of hospitals. I am aware of the fact that a number of these women have continued to practise without insurance—a very risky thing indeed. But the problem has extended into our universities. While some of these issues have been dealt with, we still have problems with midwifery students and some nursing students actually getting insurance so that they can do their clinical placements and then graduate.

For those people who argue that midwives cannot get insurance because they pose too high a risk or that we really should not worry about insurance for midwives because Australian women prefer the medical model, I want to dispel those myths. Firstly, independent midwives cannot get insurance, despite the fact that midwife assisted pregnancy and delivery for healthy women is the preferred option for many women if that choice is available and despite the fact that there has never been a successful litigation against a registered midwife in Australia. The WHO recommends the midwife as:

... the most appropriate and cost-effective type of health care provider to be assigned to the care of normal pregnancy and normal birth.

The OECD countries with the lowest peri-natal mortality rates have maternity care systems in which midwives provide primary care for up to 80 per cent of pregnant women. The truth is that maternity services primarily delivered by midwives are safer, the rates of intervention are significantly lower, the rates for breastfeeding are significantly higher and Indigenous babies in particular seem to benefit, with fewer born underweight.

Now that we have dispelled the myths, let us go back to the government's approach. The health minister's comments in this area have not been consistent. She said:

Medical indemnity, like all insurance, is facing significant issues. We have the state health ministers coming together with the medical defence organisations and leaders in that industry, with the medical profession itself, to address the medium, short and long term ... I think we need to look at the whole area, the whole field. It's very important we address the issues across the board.

Most of us took that to mean the issues across the board, and working with the states to look at a true medical indemnity insurance package—not a doctor indemnity insurance package. Addressing the issues across the board would involve a closer look at why we have this medical indemnity crisis. If the government had begun to look at why, I think it could have sorted out some of those problems, particularly in the high-risk area of obstetrics. Why are the premiums for obstetricians spiralling? I understand that some of them pay up to $60,000 a year. Why are more women suing their obstetricians? What is the problem out there?

There are a range of other issues, besides ones relating specifically back to maternity services, such as the availability of other supports if the baby is facing long-term needs. We all know the disability payment for children is very small and quite difficult to access. Let us concentrate for a moment on the actual medical issues. Recent media reports suggest that up to 70 per cent of specialists will have left this area by 2012. I do not know whether this is simply scaremongering, but it is a constant reporting back of the number of specialists who feel like just walking away from the profession. I make it clear that I am certainly not attacking those professionals who are doing a tremendous job delivering babies, particularly those facing very difficult circumstances in rural and remote areas. They definitely deserve all our support. However, I think we need to look at the way we deliver maternity services as a whole in this country, because it is a huge part of the problem. It has to be addressed if we are to make any long-term changes.

For a range of reasons, Australia is locked into a highly specialised medical model for delivering normal babies. According to recent research by the University of Newcastle, the use of surgical procedures and drugs in childbirth is now so common that many women are doubting their ability to give birth naturally. Again, I am not criticising the doctors. It is becoming an expectation. Women are actually asking to have a caesarean. If their friend had a baby delivered by caesarean they think that is the way, so they ask their obstetrician. It is very difficult, in this litigious environment, for the obstetrician to say no.

If we look at the cost of this model, we see that it is wasting millions of dollars by treating healthy women, with normal pregnancy, as specialist cases. According to the author of some research from the University of Newcastle, Professor Kathleen Fahy:

Women under the care of obstetricians will have twice as many caesareans as those being cared for by midwives. There is an absolute correlation that the more medical intervention there is, the more complications you will have ... With less medical intervention, you'll make less mistakes.

We have an alarmingly high rate of obstetric intervention in Australia, and from the statistics it now seems that something like 80 per cent of births have some sort of medical intervention. That is a staggering figure given that the WHO suggest it should be somewhere around 15 to 20 per cent. In addition, our very high rate of caesarean births is some 15 per cent higher than the WHO target. Going with this high rate of intervention, the most recent maternal mortality report shows increased numbers of maternal deaths. Australia's high rate of intervention in childbirth is unsustainable. Each intervention increases the cost of maternity services as well as the risk of litigation.

I take this opportunity to suggest an alternative—it is only part of the solution to the professional indemnity crisis but it is something this government should consider working through with the states, because it would save an enormous amount in public health expenditure—and it is community based midwifery. We are not talking about a situation in which, when a women turns up at the hospital, the first person she sees as she is about to give birth is the midwife—until the doctor arrives. We are talking about community based midwifery, where she is supported throughout her pregnancy by the midwife. The midwife ensures that the home is ready for baby. The midwife will be there at birth, whether the woman chooses to give birth in hospital—which is what happens with the midwifery program in the northern suburbs of Adelaide—or the family chooses for the birth to happen at home. The midwife will then follow the woman through for the first few weeks of baby's life.

In New Zealand, this program of choice sees some 70 per cent of women choosing the community midwife as their primary care giver. Firstly, it delivers substantial costs. We have the potential in Australia to save an enormous amount of money for the state and federal health budgets. Secondly, it overcomes the problem of the withdrawal of obstetric specialists, by providing community midwifery services to complement them in their role in the health system. If it is right that in 10 years we will have only about 30 per cent of the current work force of obstetricians left, those who can take their place are the community midwives. The obstetricians will be there for those women who do need some surgical intervention and some specialist medical support.

Thirdly, it would improve the risk profile of Australia's maternity services by lowering intervention rates and reducing the likelihood of litigation. The experience in New Zealand has shown that the insurance problem can be largely resolved by providing women with the choice of a known midwife, by ensuring ongoing information and support throughout a pregnancy and by establishing appropriate counselling and mediation systems, where a woman's grief over a difficult birth where a healthy baby is not the end result is treated with respect. The woman is well supported to understand what happened and why rather than being treated defensively as a potential litigation risk.

Fourthly, it would bring Australia into line with international best practice. Fifthly, it would better meet the needs of Australian women. It would give them and their families a choice in terms of greater continuity and one-to-one care. Finally and sixthly, it would address the dramatic decline in regional maternity services in recent years as community midwifery services can be readily and cost-effectively established in urban and rural and regional settings.

To return to the amount of money I mentioned at the beginning of my speech, which was $35 million from the government, all the Australian College of Midwives wanted when they approached the federal government earlier this year was $1 million. At that stage that would have ensured the provision of insurance to community midwives then struggling to get insurance. And they were not struggling because of any risk. They were struggling to get insurance because insurance companies decided that they could not be bothered—there were not enough of them and they would simply write that whole area off their books to save any hassles and, indeed, any paperwork.

My final comment about this issue and this legislation is that the decision by the federal government to provide professional indemnity insurance for only a portion of the medical profession—only for doctors—appears to contravene the spirit of the national competition policy. It also directly conflicts with the many recommendations of some 30 state, territory and Commonwealth inquiries into maternity services since 1985. They have stated the need for midwifery-led community based care to enhance the care now provided by obstetricians. I believe that the time is now well and truly overdue for this government to take some leadership on this issue, to work cooperatively with the states and to tackle the professional indemnity problems for all health professionals and not just the chosen few. I foreshadow that I will move a second reading amendment—it has been circulated—which specifically deals with the lack of interest this government has in supporting midwives.