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Monday, 15 March 2010
Page: 1828


Senator FIERRAVANTI-WELLS (8:00 PM) —I rise tonight to speak on the Health Legislation Amendment (Midwives and Nurse Practitioners) Bill 2009 and related bills. The purpose of these bills is to amend the Health Insurance Act 1973 and the National Health Act 1953 to enable nurse practitioners and midwives to request diagnostic, imaging and pathology services for which Medicare benefits may be paid. It will also allow these health professionals to prescribe certain medicines under the Pharmaceutical Benefits Scheme. The new Medicare benefits items will be for services provided by nurse practitioners and midwives working collaboratively with doctors. The midwifery components of the bills implement the recommendations of the Maternity Services Review. This is significant legislation and has generated a strong and emotive response. The minister for health was also forced to write to the chair of the inquiry to clarify the intention of collaboration as a result of concerns raised by stakeholders.

The legislation has also been the subject of two Senate inquiries. The bills were initially considered by the community affairs legislation committee in August last year. The committee examining this legislation received over 1,800 submissions and was due to report on 7 August. The reporting date was moved to 17 August due to the overwhelming public reaction. However, on 29 November 2009 the Senate again referred the bills for inquiry, but this time together with the government’s proposed collaborative arrangement amendments. This inquiry again generated considerable interest and within a very short period of time the committee received 933 submissions relating to the bills and amendments and also received 430 comment letters and 900 form letters. The inquiry report was tabled in February 2010.

Can I just pick up on some of the points that Senator Parry and Senator Siewert have made: it is really disingenuous of Minister Roxon to come in here and criticise the Senate. The reason that this series of bills has had such a chaotic iteration has been that this minister has bungled the handling of these bills. Why should we be surprised given the bungling that this government has made of health? It does not surprise me at all that we have seen another example of Minister Roxon’s bungling.

These bills extend subsidised indemnity insurance to eligible midwives, and a lot of the detail giving force to these bills will follow by way of regulation. In the first instance the coalition and the public were given scant detail by the government on this critical future regulation. The government has yet to provide the actuarial modelling for the indemnity insurance scheme other than a very simplified explanation provided to the Senate community affairs inquiry by departmental officials. It causes concern that once again the minister has rushed headlong into legislation with the attitude of, ‘We’ll work out the details later.’ It is clearly not the responsible way to legislate, and as we have seen time and time again from this Labor government it leads to mistakes, oversights and bungling. The parliament and the public are entitled to detail of policy and legislation that is to be voted on.

According to the bills, an eligible midwife is a person who:

(a)   is licensed, registered or authorised to practice midwifery by or under a law of the Commonwealth, a State or a Territory; and

(b)   meets such other requirements (if any) as are specified in the Rules for the purposes of this paragraph; and

(c)   is not included in a class of persons specified in the Rules for the purposes of this paragraph.

We learnt of possible extended classes of midwives in the minister’s second reading speech, where she stated:

… the Commonwealth supported professional indemnity cover will not respond to claims relating to homebirths.

It is the intersection of these bills with the National Registration and Accreditation Scheme where serious and genuine concerns arose. The Health Practitioner Regulation National Law Bill 2009, under ‘Eligibility for general registration’, states:

(d)   there is, or will be, in force in relation to the individual appropriate professional indemnity insurance arrangements, including a policy held, or arrangements made, by the individual’s employer that will cover the individual …

Under this, in accordance with clauses 128 and 129, an individual who practises as a midwife without indemnity insurance and is therefore unregistered would have been subject to a financial penalty.

Come 1 July 2010, given the minister’s original position, midwives would have effectively been prohibited from providing birthing services outside of a clinical setting. This was an issue that was fundamentally about choice. It was extraordinary for the health minister to assume to effectively prohibit mothers and parents around the country from having an appropriately qualified health professional in attendance at childbirth. I acknowledge and accept that there is a great diversity of opinion on homebirthing, both within the medical and health fraternities and in the wider community. However, I am not here today to debate the merits or otherwise of homebirthing. That is for others. I am here to emphasise the right of intelligent, informed Australian adults to have a choice, to be entitled to decide for themselves. Childbirth is an intimate and personal decision for families in consultation with health and medical professionals. It is not appropriate for the Rudd government or Minister Roxon to mandate the conditions of childbirth for all women across Australia.

20:06:54 This is a nanny state Labor government treating with contempt the rights of mature adults to make informed decisions. For that reason, I am glad to see that the proposed registration requirements have been amended to allow existing services to continue. After months of prevarication, in her letter of 8 December 2009 to the chair of the committee, Minister Roxon said:

I am persuaded that it is not necessary or desirable to proceed with the collaboration amendments to the Midwife Professional Indemnity (Commonwealth Contribution) Scheme Bill 2009.

I now turn to the Pharmaceutical Benefits Scheme and the Medical Benefits Scheme access for midwives and nurse practitioners. There needs to be a more holistic approach to health care in Australia especially in the areas of preventative health and chronic illness. The skills of all health and medical professionals should be utilised to their full potential in accordance with appropriate scope of practice. Practice nurses, for some time, have been an invaluable and integral part of primary health care in Australia. Their role, skills and professional development will be central as we go forward. However, extending access to the PBS and MBS has significant ramifications in terms of scope of practice, patient safety and the economic viability of the health budget.

The interest bill alone on the Rudd government’s huge debt will make it hard in future years to meet the extra expenditure on the schedules and other expenditure across the health system. It is important that PBS and MBS access for all professions is carefully considered and monitored in accordance with professional qualifications and experience.

The coalition firmly believes that GPs are the cornerstone of primary health care in Australia. It is important that there is genuine collaboration between other health professions and GPs in managing patient health care. We have not received any clear detail on the so-called collaborative model, which is central to these bills. What we do not want to see is a two-tier system in Australia. Anyone who wishes to see a doctor for their healthcare needs should be entitled to do so. We do not want to see a situation where Australians have to see a nurse, not because they want to or because it is convenient but because it is an easier solution for this government. We need to see a genuine model of collaboration of GPs working with other health professionals and specialist practitioners in managing patient care. It is important that there are appropriate guidelines for a scope of practice in ensuring patient safety and the economic viability of the PBS and MBS.

The government’s current investment in the PBS and MBS is significant. As at 30 June 2007, the coalition government spent $6.4 billion per annum on pharmaceutical benefits. Coalition government expenditure on the MBS was some $11.7 billion as at 30 June 2007. This is a significant increase from 1995-96 amounts under the last Labor administration of $2.2 billion and $6 billion respectively.

It is important that these programs are utilised as effectively as possible and that they remain viable into the future. However, in order to consider that issue, the government needs to release the detail under which this legislation will operate. There is still a conspicuous and concerning lack of detail behind these bills. The creation of referral rights for nurse practitioners to specialists is another significant component of this legislation. However, once again, we need to be assured of the efficiency of such a model. Currently, GPs refer only a very small proportion of patients to specialists. We asked the government to release the modelling or at least some sensible detail as to how this measure may affect the quantity of referrals, waiting times for specialists and the MBS.

Whilst there is a logical argument for nurse practitioners and midwives to have some capacity to order pathology and diagnostic services attracting a Medicare rebate, the workability and efficiency of this proposal will entirely depend on the collaborative model, which we understand the government has not yet devised. Without a national e-health record and without knowing how the government’s planned collaborative model will work, there is significant risk of duplication and over-servicing in this area.

The health budget, provided by the taxpayers of Australia, is certainly not infinite and needs to be managed carefully to make the worthy but almost endless demands placed on it. It is certainly one of the most difficult aspects of the health portfolio. There are many worthy causes that would benefit from funding in the health portfolio. However, the reality of the situation and something which we all need to remind ourselves is that funding is provided by the hard-working taxpayers of this country and the pie is only so big. There is a duty, an obligation in fact, on government to ensure that taxpayers’ money is always used efficiently. Unfortunately, this is clearly not something the Rudd government understands. We have seen billions of dollars of taxpayers’ money squandered on populist cash handouts, racking up debt for the youth of this country to pay off.

As I say, the debt-servicing requirements caused by the Rudd government’s reckless spending will cut deeply into key budget areas such as health in future years. There are a few portfolios where this obligation to ensure the best use of funds is more important than health. There is an opportunity cost to all initiatives. The stark reality of the situation is that taxpayers cannot fund everything. Policy needs to be considered and refined and there needs to be more consultation than what this government has committed itself to in the past in this portfolio. Taxpayers deserve and the government is obliged to provide the best bang for the buck.

The minister’s bungled handling of this critical legislation follows this government’s complete mismanagement of the health portfolio. I would like to take a few moments to dwell on this. Mr Rudd and Minister Roxon made numerous explicit and unambiguous promises that a decision to hold a referendum to take financial control of public hospitals would be made by mid-2009. For example, a media release by Nicola Roxon and Kevin Rudd on 23 August 2007 stated:

If by mid-2009 the Commonwealth and the states and territories have not begun implementing the National Health Reform Plan, a proposition for the Commonwealth to assume full funding responsibility will be developed and put to the Australian people.

As at 30 June 2009, Mr Rudd had failed to state whether he would honour this promise. However, some confusion is understandable given that Mr Rudd has gone to some great lengths to retract it.

A paragraph referring to the referendum was removed from the Prime Minister’s website between October and November 2008. Under questioning in this parliament the Prime Minister failed to say why this had occurred. In addition, a heading ‘Fixing our hospitals’ on the Prime Minister’s website was replaced with ‘Improving our hospitals’ during the same period. And how can we forget the evidence given to Senate estimates on 10 February by the head of the Department of Health and Ageing, when it was revealed that the incoming Rudd government did not have one document to hand across to the department to implement its plan to fix hospitals? Not even a back of the envelope plan for fixing hospitals could be produced. And yet, magically, on 3 March, the Prime Minister announced his grand plan for health. I think there was a lot of scurrying between 10 February and 3 March so that they could cobble something together which vaguely resembled something called a health plan.

The Prime Minister’s plan was not considered by cabinet and is very light on policy detail, to say the very least. It was hastily put together—indeed, cobbled together. Premier Keneally, amongst other premiers, said that she had only found out about Mr Rudd’s health plan on the morning of the announcement. Mr Rudd has now become a travelling health salesman, but without the free pens and the samples. His mission is to whack the recalcitrant states of Queensland, New South Wales and Victoria to persuade their premiers to sign up to his plan next month at COAG. Mr Rann has gone along willy-nilly in the vain hope that this will save his hide.

I come back to the bills before us. I would like to conclude by reading the additional comments by coalition senators to the second inquiry of the Senate Standing Committee on Community Affairs, tabled in February 2010:

Significant concerns were originally raised about the affect of the amendment on the ability of Midwives to gain indemnity insurance and therefore be registered. The Minister has since given notice that the Government will withdraw the amendment relating to the Midwife Professional Indemnity (Commonwealth Contribution) Scheme Bill 2009. The Coalition Senators acknowledge the importance of an appropriate collaborative arrangement that provides for patient safety and confidence.  Mothers-to-be and midwives have not been assisted by the Health Minister’s numerous changes in policy direction and the Coalition will reserve the right to consider the regulations that define the nature of collaborative arrangements between nurse practitioners, midwives and medical practitioners.

That is the real reason why this bill has been delayed. I come back to my original comments: it is absolutely disingenuous of Minister Roxon to try and blame this Senate. The reason that this legislation has been delayed and has taken so long to come here is because of her bungling and her inability to properly deal with this matter. In the end, she had to admit that she had got it wrong and had to backtrack. It is not the only time she has backtracked; she seems to be making a habit of it.

Whilst we will not be opposing the passage of this bill, the coalition remains concerned about the nature of the collaborative arrangements between nurse practitioners, midwives and medical practitioners and will consider the regulations once they finally become available. The implementation of this health measure will also be closely followed.

I refer to the proposed amendments that Senator Siewert has flagged and advise that the coalition will not be supporting those amendments. Later in the debate I will be making some additional comments in relation to that.