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National registration and accreditation scheme for doctors and other health care workers

CHAIR —Good morning. I welcome representatives from the Australian Peak Nursing and Midwifery Forum. We have your submission. Thank you very much. I now invite any or all of you to make an opening statement and then we will go to questions. Have you tossed up who is going to go first?

Ms Cook —We have—we run a very democratic ship.

CHAIR —I would expect no less from your group.

Ms Cook —If I may, I will start by saying thank you very much for inviting us to speak to you today. The four people you see in front of you, the Australian Peak Nursing and Midwifery Forum, are a coalition of the regulators and the industrial and professional bodies relating to nursing and midwifery in this country—all of the peak bodies that have an interest in this scheme. Nurses and midwives are very committed to the implementation of national regulation and we have been for a considerable amount of time. The organisations of the Australian Peak Nursing and Midwifery Forum are united in their support for the principles of the national system as it is currently proposed. As long as the system that is implemented is focused on quality and safety, the protection of the public and support for nurses and midwives to practise safely and confidently, then we support that system.

The reason, I guess, that we are here today is that we have concerns about the architecture of the proposed system. We would like to outline our concerns, and we have some solutions for those problems that we think, if implemented, would allow us to come up with a system that meets the needs of the Australian community. Our first concern revolves around financial and human resources. The current state of play with nursing and midwifery regulation in Australia is that the boards are statutory authorities and have access to all of the revenue generated by nurses and midwives’ fees and use that money to hire and fire their own staff and administer their legislation on behalf of the ministers. The current architecture that is being proposed has a number of other administrative layers and a number of additional bureaucracies which obviously will need to be funded, and at this point in time that funding comes out of the fees generated by nurses, midwives and other professionals covered under the scheme. The other issue with that is that the current architecture that is being proposed has a system whereby the boards do not have access to hire and fire their own staff—their own human resources. There are a couple of states in this country which have existing schemes and those sorts of governance structures, and they are problematic.

If a board is going to develop policy around the regulation of a health professional, the board then has to be able to communicate that policy to the health professional, because it goes to the heart of their practice and their capacity to practise safely. If, due to resource issues—because it does not control its own finances or its own staff—a board is not able to communicate that policy decision to a nurse or a midwife, there is a very real possibility that there will be an issue in terms of harm to the public. So from our point of view it is critical that the Nursing and Midwifery Board of Australia have access to all of the resources it needs to do its job properly. We are concerned that under the current scheme that is not the case. Certainly in bill A, the health professions agreement that has been articulated does not go as far as we would like it to go. It talks about fees, funds and budgets, but it has nothing about human resources.

As you will see in our submission, currently the legislation says that the health professions agency management committee ‘may’ negotiate an agreement with the board. There is no compulsion for it to negotiate that agreement. That tells us that, if the agency management committee chose not to, all the revenue raised would go into consolidated revenue and the committee would employ whichever staff it needs. When the board decided that it needed to communicate with its registrants, it may not have the capacity to do so. That is a very big issue and a very big concern for us and it goes right to the heart of public safety, which is why we regulate nurses, midwives and other health professionals. Barbara is now going to talk to you about another issue, which also goes to the heart of public safety.

Dr Vernon —The issues I would like to pick up on is in relation to access to professional indemnity for midwives.

CHAIR —I am not surprised!

Dr Vernon —That is right! We totally support that being a provision. We think it is important that women have access to some financial assistance with the implications of any kind of adverse outcome if there is found to be negligence involved. But, as you would probably be aware, since 2001 that has not been something midwives can access. We believe that it will very much be an issue of quality and safety for women who are currently making the choice, and are likely in the future to continue to make the choice, to access the care of a private midwife.

If they are no longer able to access the care of a midwife who is registered then it is anticipated there would be an increase in a trend that is already occurring because of a shortage of those people, where they are choosing to birth at home with no health professional in attendance. I think there was a high-profile example of that in the media a few weeks ago where, tragically, the mother’s baby had actually died during labour when she had made that choice.

In terms of observation of other countries, we think that where there is no longer access for women to a registered midwife to provide care in the community for the small minority of women who make that choice, that you tend to get that practice continuing, and it continues in a much less safe, transparent and accountable way than when those health professionals are actually registered, when they are accountable to the regulatory board and when they can be well linked in to a maternity service if that woman or baby actually need medical input to their care.

So we would certainly like to see every effort given to making access to indemnity available to midwives ahead of the national registration scheme. Indeed, it probably needs to be available within the next few months given that the gestation period means that some women will be planning that care from September or so this year and they are very anxious already about the implications of the introduction of the scheme. We certainly think there is a fairly immediate solution available for that in extending the same kinds of supports to midwives that federal government has already provided to obstetricians. We do have advice from the insurance sector that that would be likely to reinstate the market for professional indemnity for midwives—that they would be able to access policies. Karen was going to speak further, I think, about another issue. Is it Karen, or Lee?

Ms Thomas —My name is Lee—Lee Thomas.

Ms Cook —Sorry, Lee.

Ms Thomas —There is one issue in particular that my colleague Barbara did not raise and that is that we would like on the record a note that we are of a consensus view that there should be a separate register for nurses and a separate register for midwives. We have consistently said that. Nursing and midwifery are considered two separate professions now. We are all in the process of changing our names—to the Nursing and Midwifery Federation, the Nursing and Midwifery Council, whatever it might be—and I think that is an important point. So thank you for that.

CHAIR —Does that exist anywhere now?

Ms Thomas —Yes, there are five already regulated.

Dr Vernon —In five of the eight jurisdictions, that is already regulated.

CHAIR —So we are not asking for anything different to anything that is—

Ms Thomas —No.

Senator BOYCE —That 300,000 figure you have given is nurses and midwives?

Ms Cook —The 300,000 is the number of nurses and midwives holding current registration in Australia.

Senator BOYCE —Can you split that for us?

Dr Vernon —It is estimated there are 15,000 midwives, but the estimates are fairly unreliable because the three jurisdictions that do not have separate registers are unclear about how many professionals they have.

Ms Thomas —I do think that is another issue: the timeliness and the effective collection and then distribution of work force data. I think that kind of fits with your question as to whether or not we know the figures. Yes, we have rough estimates but good, well-distributed, well-collected workforce data is terribly important to our professions—and to many of the others but, of course, we will only speak for ourselves. You would all be aware that we are facing a very critical shortage of nurses and midwives in this country, so good workforce planning is important.

There is another issue. I will not labour this point, because I understand that our previous colleagues have given evidence about the professional standards and accreditation standards and the connection to the ministerial council. We continue to raise concerns with you about what we would say is the ministerial council’s perceived, or real, right of veto over our professional standards and our accreditation standards. We have been consistent and, in fact, quite longwinded in our objection to their influence and their ability to be able to alter, to reject—or to accept, for that matter—the profession’s standards. I think that there is probably some evidence that we have where this has happened previously, and we would like to give you that evidence in camera.

CHAIR —We could do the public element first and then dedicate time for the in camera part. It is just easier for the process if we do it that way.

Ms Cook —Yes.

Ms Thomas —I am not going to labour that point any further; I think you know our issue. We are happy to take questions from you now.

Senator HUMPHRIES —Is the first issue you raised, the independent resourcing of the new board, one you think could yet be dealt with when some of the detail is put on the table by the processes underway at the moment, or do you feel the door has been firmly shut on that issue and that you are not going to get the sorts of resources that you were calling for to deal with these issues?

Ms Cook —Based on your reading of bill A, it has not yet been dealt with. As you said earlier, Senator Moore, we are still waiting with breathless anticipation for bill B and have been for a considerable period of time. We think the issue could be dealt with if the legislation stated quite clearly that the agency management committee must negotiate these agreements with the board—not ‘may’ but ‘must’ negotiate the agreements with the board—if the agreements were extended to cover fees, funds, budgets and professional staff. All of the nursing and midwifery boards currently employ nurses and midwives, and it is critical, particularly when we are dealing with breaches of professional standards and thinking about the context of those breaches of professional standards, to have that professional expertise at hand to assist in those judgments. So it is fees, funds, budgets, professional staff and access to all of the fees generated.

The obvious concern we have for nursing and midwifery, when we talk about a cross-professional office and we look at the volume of nursing and midwifery, is that nursing and midwifery money will be used to cross-subsidise other professions. Given that enrolled nurses are probably the most poorly paid of all the health professions we are talking about in this scheme, it is not appropriate that they should be cross-subsidising other, much more generously remunerated professionals. It is about having access to all of the money, being able to negotiate with the agency management committee what the fees would be and then being able to employ their own professional staff within those cross-professional offices. We think that those things could be done under the next branch of the legislation.

Senator HUMPHRIES —We asked about the extent of cross-subsidisation between different occupations and were told that there would be no cross-subsidisation, but we are yet to see the way in which that has translated into legislation or administrative schemes. How much does the arrangement you are suggesting to us now reflect what is already taking place at the state registration board levels?

Ms Cook —All of the state registration boards are currently self-funding apart from two which have different governance models where all of the money raised by nurses and midwives’ fees goes into consolidated revenue and the government then employs staff under the health department to provide secretariat services to the board. Those are the two who, based on their experiences, have expressed their concern about this as a governance model. Those are the two who find that in their legislation they have the capacity to do things but because of lack of resources are not actually able to do those things, and that is not right.

Senator HUMPHRIES —On average, roughly how many nurses and midwives does each board presently employ? Let us say Victoria, for example.

Ms Cook —It would be very difficult to give you the figures, because if you talk about a small board like the ACT, where there are 5,000 nurses registered, they probably have six staff, half of whom would have a nursing and midwifery background. If you then go all the way to somewhere like Victoria, which has one-quarter of the nurses in this country, they have substantially more staff. It is difficult to give you an exact figure on that.

Senator HUMPHRIES —Do you know if the other occupational groups have the same kind of structure? They have physiotherapists, podiatrists or whatever on—

Ms Cook —My understanding is that most of the other occupations do also employ professionals, yes.

Senator HUMPHRIES —To come to this question about independence, we have been trying to tease out with our earlier witnesses today, particularly Dr Morauta, what is likely to happen. She explained that the scheme was meant to engineer the kind of independence which the professions and occupations currently enjoy under the present registration scheme. We are told that the boards will be made up mostly of people in that particular occupational group and a few consumer representatives of the community. There will be no public servants on the board, we are told.

CHAIR —Unless—

Senator HUMPHRIES —Unless they happen to be—

Ms Cook —Unless they happen to be wearing another hat.

Senator HUMPHRIES —They might happen to be a public servant, but they are there to represent the consumer interest.

Ms Cook —Yes.

Senator HUMPHRIES —We are told that, although it is the ministers that finally tick off on the standards, it is the boards that determine the standards that will operate in terms of admission of new practitioners and disciplinary matters and so on. Those standards will be set by the boards. They will lob them up to the ministers, and the ministers can accept or reject them but they cannot change them or recommend that certain things be done to change them. The driving force to make those things happen will be the boards. They will liaise with their state committees, which deal with the day-to-day registration and disciplinary matters, to make sure that they are reflecting the current standards in that particular profession. Now, the national scheme advocates profess that they do not want to lower standards, but there is a consistent concern from groups like yours that have come before us that standards may be lowered. How seriously do we take those warnings, given that the architects of the scheme seem to be saying to us, ‘No, we’re not going to let standards fall’?

Ms Cook —We are talking about a range of standards here. So, for nursing and midwifery, there are standards for the accreditation of courses, and they are the standards which decide what the educational preparation should be for nurses, enrolled nurses, nurse practitioners and midwives. We are then talking about what we call the professional practice framework: the code of ethics for nurses and the code of ethics for midwives; the code of professional conduct for nurses and midwives; the competency standards for enrolled nurses, registered nurses, midwives and nurse practitioners; the national decision-making frameworks; the continuing competence frameworks; and the guidelines on professional boundaries issues. So we have a matrix of professional practice standards which support nurses and midwives to practice safely and which are currently developed by the boards in conjunction with the community and the ANMC.

The standards for the accreditation of courses are a subtly different matter, and these are the standards which we are even more concerned about. You said that the ministerial council would have the capacity to approve or reject those standards, so the question would be: in the event that they decided to reject those standards, what would happen then? We do have evidence that we would like to speak about in camera on that matter.

Ms Thomas —Yes. I think the other issue is: if the ministerial council does reject an accreditation standard, on what basis is it rejected when a board may be able to demonstrate very adequately and clearly that they have gone through a genuine consultative process with the profession concerned and with consumers, and they are standards that will indeed protect the public? Why then would the ministerial council have any power to reject them?

Senator HUMPHRIES —The response to that sort of question, when we put it to Dr Morauta, was that within the state structures at the moment the decisions about standards are actually made by the ministers there, either as a determination by them or even as a disallowable instrument that parliament can reject. It is not clear whether the state parliaments would be able to reject the standards made under this process; that is yet to be worked out, we are told. But we are told that that sort of level of independence is trying to be engineered. How would we redesign the scheme so as to ensure that that independence, that absolute control of standards in the hands of the professionals, is preserved?

Ms Cook —I think that what you would do is give the national board the capacity to approve those standards, but you would have in place business processes which the board must follow in the development of those standards. Because national registration and accreditation is starting in July 2010 and because nursing and midwifery currently does not have an existing national body that does the accreditation of courses—it is currently done by the states and territories—we have been running a project to develop national standards for the accreditation of those courses ahead of that scheme.

That project has taken two years to run. It has involved all of the organisations you see in front of you. It has involved thousands of nurses and midwives around the country. It has involved analysis of other countries and other professions to see what sorts of standards they have and a huge amount of consultation with consumers to come up with standards for the educational preparation of nurses and midwives which are robust and which produce nurses and midwives who are safe and competent to practise. If those standards were to go to a ministerial council now and be rejected, on what basis could you possibly reject a set of standards that have been so rigorously developed and that are doing the job they are meant to do? And, if they were rejected, where would you go then? What on earth would you do then?

Ms Cerasa —The profession would be stymied, and our view is that patients would suffer.

Senator HUMPHRIES —But the boards in the states do not have the power to set those sorts of standards now. If we did not have this structure and you sent those new standards to all the state boards, they could theoretically be bounced by the state ministers, couldn’t they?

Ms Cook —Yes.

Senator HUMPHRIES —So why should the collective ministers not be able to bounce the standards at the federal level?

Ms Thomas —I think that goes to our evidence in camera.

Senator HUMPHRIES —Okay. I am looking forward to this.

CHAIR —Does anyone have any other questions generally, not on that issue? I think that is the crux of the issues. Certainly we are very much aware, Dr Vernon, of the issues around the medical indemnity and the process with midwives. Not asking questions does not mean we do not take it extraordinarily seriously; it is just that we have all been aware of that for a long time, and I think most of us have advocated for it. Because I think this is a core issue in your evidence, we might go in camera now and then give people an opportunity to flush out the issues that you evidently want to tell us about.

Evidence was then taken in camera but later resumed in public—

[1.33 pm]