Health Legislation Amendment (Midwives and Nurse Practitioners) Bill 2009 and two related bills
The Inquiry
1.1
On 25 June 2009 the Senate, on the recommendation of the Selection of
Bills Committee (Report No.10 of 2009), referred the provisions of the Health
Legislation Amendment (Midwives and Nurse Practitioners) Bill 2009 and two
related Bills to the Community Affairs Legislation Committee for inquiry and
report by 7 August 2009. The Committee presented an interim report on 7 August
and indicated that it would table its final report on 17 August 2009.
1.2
The inquiry generated considerable interest and within a very short
period of time the Committee had received nearly two thousand submissions,
primarily from midwives who provide homebirth services and from parents who
described their experiences with, and support for, home birthing. The Committee
received 1,958 submissions relating to the Bills and these are listed at
Appendix 1. The Committee considered the Bills at a public hearing in Canberra
on 6 August 2009. Details of the public hearings are referred to in
Appendix 2. The submissions and Hansard transcript of evidence may be accessed
through the Committee's website at https://www.aph.gov.au/senate_ca.
1.3
The Committee notes that a predecessor Committee, the Community Affairs
References Committee, considered a number of the issues that have been raised
during this inquiry, including homebirth and midwife indemnity insurance,
during earlier inquiries into childbirth procedures and nursing.[1]
The Bills
Health Legislation Amendment (Midwives and Nurse Practitioners) Bill 2009
1.4
The purpose of the Bill is to amend the Health Insurance Act 1973 and
the National Health Act 1953 to enable nurse practitioners and
appropriately qualified and experienced midwives to request appropriate
diagnostic imaging and pathology services for which Medicare benefits may be
paid. The Bill will also allow these two groups of health professionals to
prescribe certain medicines under the Pharmaceutical Benefits Scheme (PBS). New
Medicare items will be created and allow for the referral under the Medicare
Benefits Scheme (MBS) from these health professionals to specialist and
consultant physicians. The proposed arrangements will be available from 1 November
2010.
1.5
Amendment of the Health Insurance Act will allow a 'participating nurse
practitioner' or 'participating midwife' to request or provide certain Medicare
services. Under proposed amendments to the National Health Act, an 'authorised
nurse practitioner' or 'authorised midwife' will be authorised to prescribe
certain PBS medicines. Prescribing under the PBS will only be permitted within
the scope of practice of an authorised nurse practitioner or midwife and in
accordance with the State or Territory legislation under which they work.
1.6
The proposed arrangements require that the nurse practitioner or midwife
be an 'eligible nurse practitioner' or 'eligible midwife'. To be an 'eligible
midwife', the Bill requires registration as a midwife and additional
requirements specified by legislative instrument must be satisfied. The minimum
core requirement of being an 'eligible nurse practitioner' is registration as a
nurse practitioner.
1.7
For midwives and nurse practitioners to be eligible to participate in the
MBS and PBS arrangements, they will have to demonstrate that they have
collaborative arrangements in place, including having appropriate protocols
with hospitals and doctors.
1.8
The Pharmaceutical Benefits Advisory Committee will be consulted about
the range of medicines that each group can prescribe and the circumstances
under which the medicines can be prescribed.
1.9
The Minister commented:
In short, this Bill removes barriers to the provision of care
and will lead to improved access to services for the community. It is a long
overdue recognition of our highly skilled and capable nursing and midwifery
workforce.[2]
Midwife Professional Indemnity (Commonwealth Contribution) Scheme Bill 2009
1.10
The purpose of the Bill is to allow the Commonwealth to provide, via a contracted
private sector insurer, affordable professional indemnity insurance to eligible
privately practicing midwives. The government supported scheme for eligible
midwives will enable the Government to address a market failure which has
resulted in privately practising midwives being unable to access professional
indemnity insurance cover from a commercial insurer since 2002.[3]
The implementation date for profession indemnity is 1 July 2010.
1.11
The Bill provides that the Commonwealth will pay certain amounts for
claims against an eligible midwife. In the case of practicing eligible
midwives, the Bill will provide as follows:
-
for each claim, the insurer will pay the first $100,000;
-
for each claim over $100,000 the Commonwealth will pay 80 per
cent of the cost that exceeds that threshold up to a ceiling of $2 million
(these are referred to as Level 1 Commonwealth contribution payments); and
-
for each claim that exceeds $2 million, the Commonwealth will pay
at the Level 1 rate for the first $2 million, plus 100 per cent of the cost of
the claim above that threshold (these are referred to as Level 2 Commonwealth
contributions).[4]
1.12
The Bill provides for the $100,000 and $2 million thresholds and rate of
subsidy applying to both Level 1 and Level 2 claims to be changed by Rules.
1.13
For Level 1 and Level 2 Commonwealth contributions a claim will only be
paid if the claim has been certified as a qualifying claim by the Medicare
Australia Chief Executive Officer.
1.14
For the purposes of the Bill, an eligible midwife is one who is
licensed, registered or authorised to practise midwifery under a State or
Territory law and who meets any other requirements specified in the Rules.
1.15
The Minister, in her second reading speech commented:
This bill is an important component of the government's
maternity reform package. The package will improve the choices that are
available to women in relation to maternity care...
Overall, this bill contributes to a new era for midwifery
services in this country, by addressing a longstanding impediment that has
limited the availability of a wider choice for women.[5]
Midwife Professional Indemnity (Run-off Cover Support Payment) Bill 2009
1.16
Under the run-off cover scheme eligible midwives claims will be paid out
by the Australian Government and the cost of this scheme will be funded by a
levy on eligible insurers.
1.17
The run-off cover scheme Bill proposes the levying of a tax on eligible
insurers. The tax will ensure that contributions can be made to a pool of funds
that will be able to be drawn upon in the future to meet the cost of claims
against eligible midwives who leave the midwifery workforce due to retirement,
death, disability or maternity.[6]
1.18
The run-off cover scheme Bill provides that the rate of support payment
must not exceed 15 per cent with the actual rate to be set on advice from the
Australian Government Actuary.
1.19
The Commonwealth will commit $5 million in 2010–11 to assist in covering
such claims in the period before sufficient funds are accumulated through the
ongoing contribution of support payments.
Issues
1.20
The proposed legislation was generally supported by submitters. The
Maternity Coalition, for example, stated:
The reforms promise women the option of employing a midwife
of their choice, who is working in private practice (within a range of possible
models), who is accredited to receive Medicare funding and subsidised
insurance, and has collaborative arrangements with doctors and hospitals. The
goal of these reforms is to provide mothers with "safe, high-quality and
accessible care based on informed choice" (Maternity Services Review).
This is a historic breakthrough for Australia's health care
system. It promises to, over time, improve the accessibility, quality, safety
and cost-effectiveness of Australia's maternity services, by building a primary
care foundation which is currently missing for most women.
We are particularly aware of the potential in these reforms
to improve services and outcomes for rural women, who have significant problems
accessing maternity care.[7]
1.21
However, while the proposed reforms were generally welcomed, a number of
issues were raised during the inquiry, particularly the issue of midwife
support for those who wish to birth at home.
Homebirths
1.22
Under the proposed legislation, the indemnity arrangements will not
apply to homebirth midwives. The legislation will then intersect with the
National Health Registration legislation which will require all health
professionals to hold indemnity insurance. As noted by a number of submitters,
privately practicing midwives have been unable to secure indemnity since 2002
and thus 'creates a situation whereby midwives providing homebirth care will be
acting outside their registration by not holding Indemnity Insurance to cover
their practice'.[8]
1.23
Ms Dianna Kidgell of the Australian Nursing and Midwifery Council
commented that homebirth midwives were not excluded from the legislation
because of lack of qualification or competency:
I will speak to the exemption of a group of persons who are
correctly qualified and registered to practice from their area of practice when
there is no issue around competence or conduct and no reason for them to have
their practice interfered with other than the fact that it has now come through
in the legislation. We are excluding from practice a group of people who have
not changed any of the circumstances under which they are practising—they still
meet the registration requirements and have not had any reason to come to the
attention of the board for conduct or performance issues. That is a concern.[9]
1.24
The Australian College of Midwives stated that it wholeheartedly
supported many aspects of the legislation in relation to the expansion of the
role of midwives and the development of a private practice midwifery workforce.
However, the legislation 'does not enable safe quality of maternity care to be
provided for women who choose to have a baby at home'.[10]
While there are hospital-based health services in Western Australia, New South
Wales, South Australia and the Northern Territory which enable women to birth
at home, there services are very limited and operate with strict exclusion
criteria.[11]
Those women wishing to engage a private midwife for a homebirth outside these
arrangements may not be able to do so.
1.25
Many submitters commented that homebirths will still occur but with an
unregistered care provider who may or may not have qualifications or without
any assistance. As stated in one submission:
If indemnity insurance is made a requirement for midwives
nationally, then the Commonwealth Government should provide such indemnity to
independent midwives based on demonstrated competency, as such indemnity is
unavailable in the private market. If homebirth is not available through
registered midwives, the reality is that many women will still choose to birth
at home either unsupported or with the help of non-registered midwives – this
will likely worsen outcomes for mothers and newborns.[12]
1.26
The Midwives in Private Practice Subcommittee of the Australian College
of Midwives (Queensland Branch) also commented:
Exclusion of homebirth care from Medicare funding is also
likely to mean the continuation of the rise in freebirth or doula attended births
for economic reasons. Many women are now perceiving that a less expensive doula
is an adequate support for birth in the home. They see a doula as a person who
has some idea of what is happening through the birthing process. Women may
mistakenly view this as "safer" although doulas are not trained to
resuscitate mothers or babies, detect complexities or treat them, or to know
when there is a need for transfer. In some ways this presents a picture that is
even less safe than free-birthing without a doula because women may mistakenly
believe that the doula will keep them from harm.[13]
1.27
Concerns were expressed by a number of witnesses that the proposed changes
would lead to an increase in free birthing, that is, giving birth without a
trained care provider (i.e. a midwife or medical practitioner). Homebirth
Australia commented that anecdotal evidence suggests that the incidence of free
birthing is increasing and that 'the increase in freebirth is largely an
indictment on a broken maternity system that is not based on evidence and is
not woman centred'.[14]
1.28
The Australian College of Midwives argued that homebirth falling outside
the regulatory framework will result in outcomes being unreported and
invisible; those providing services not being required to have professional
qualifications; and no compunction to have appropriate collaborative processes,
back-up and transfer mechanisms.[15]
Mrs Elizabeth Wilkes, Australian Private Midwives Association, commented that
'the disasters of women turning up bleeding, with babies unable to be born or
whatever else that people are concerned about will certainly increase if this
legislation goes ahead as it stands'.[16]
1.29
The Australian Nursing and Midwifery Council concluded that 'this will
make homebirth very dangerous, even for low risk, healthy women for whom
homebirth is a safe option'.[17]
Ms Justine Caines, Secretary, Homebirth Australia, noted for example, that in
Canada after homebirth midwifery was made unlawful, one baby died at home
leading to a change in the funding arrangements for homebirth.[18]
1.30
It was also argued that midwives currently in private practice may
choose to continue to practice either underground or as unregistered
caregivers. Such midwives may not seek to update their practice through
professional development or may be less willing to transfer women to hospital
for fear of prosecution. This will impact adversely on safety.[19]
Others may be forced from the workforce altogether 'as working in hospital is
not seen as a viable option for these midwives because the fragmented systems
of care directly contradict their philosophy of birth and supporting women's
choices'.[20]
1.31
A number of submitters noted that the issue of homebirth was mentioned
in the National Maternity Service Review. The Review commented that a premature
move to a model of care incorporating homebirths risked 'polarising the
profession'. The Review also commented that it was likely insurers would be
less inclined to provide indemnity for private homebirths and if they did
provide cover that the costs would be high.[21]
1.32
During the inquiry, the safety of homebirth was canvassed. The President
of the Australian Medical Association (AMA), Dr Andrew Pesce, stated:
The government was absolutely correct when it decided not to
extend these bills to cover home births. The fundamental goal of maternity care
must be a healthy mother and a healthy baby. The available Australian evidence
on home birth is compelling: it carries significantly greater risk than
conventional options for childbirth. While there are people in the community
who want this choice, governments must make evidence based decisions. It is not
appropriate for the Commonwealth to introduce payment and insurance
arrangements that encourage or sanction activities that inherently carry more
risk.[22]
1.33
Likewise, the Royal Australian and New Zealand College of Obstetricians
and Gynaecologists (RANZCOG) does not support homebirths.
1.34
However, other witnesses argued that there was ample evidence that
homebirths for low-risk women are not unsafe. Professor Hannah Dahlen,
Australian College of Midwives, commented that 'what all this evidence tells us
again and again is that homebirth for low-risk women attended by competent,
networked, integrated midwives within a responsive system is safe'.[23]
In addition, it was argued that homebirth provided many advantages for both
mother and baby, for example low rates of intervention.[24]
1.35
The Maternity Coalition commented that 'despite the science, a heated
and ongoing debate continues in Australia about what choices women should make
in birth. This tends to be based on raw personal opinion, or at best,
"cherrypicked" evidence.'[25]
The Queensland Centre for Mothers and Babies also commented that 'the proposed
legislation appears to be based on misinformation about the relative safety of
in-hospital and out-of-hospital birth, and is reflective of the perspectives
and interests of a few groups and organisations with a vested financial
interest in hospital birthing'.[26]
1.36
The Australian College of Midwives stated that the impact of excluding homebirth
from the regulatory framework is a compromise of public safety. Further, 'it is
difficult to rationalize that this is an appropriate decision to appease medical
concerns–especially when the RANZCOG position is unable to be substantiated
with evidence and is inconsistent with the [Royal College of Obstetricians and Gynaecologists]
position statement [supporting homebirth]'.[27]
1.37
In response to the concerns raised about the exclusion of homebirths,
Ms Rosemary Huxtable from the Department of Health and Ageing (the
department) commented:
In respect of the maternity services package, that emerged
from the maternity services review. It was not the recommendation of the
maternity services review that homebirths should be included in new
arrangements at this stage. That was taken on board by the government when it
made its decisions around access to MBS and PBS. There are then other issues
which have emerged through the NRAS legislation and how that intersects with
the indemnity arrangements. We are certainly acutely aware of the concerns of
many in respect of that intersection. There has been considerable discussion.
The minister and the secretary have had discussions with stakeholders in
respect of that. There is active consideration of some of the issues that have
been raised in that regard now. But I probably cannot say too much more than
that, because there has been no final decision on those issues at this stage.[28]
1.38
Ms Huxtable also noted that homebirths are occurring in some States and
Territories and that the department is holding discussions with the States and
Territories about the services that they provide and how they fit into the
matrix of birthing services that are available. Ms Huxtable went on to comment
that 'part of this is also about a side-by-side national maternity services
plan which is being developed with the states and territories. There are a
number of streams of activity occurring.'[29]
1.39
The Committee notes that AAP reported on 11 August 2009 that, in a
statement released by her office, the Minister had commented that the
Government 'recognised the important role played by qualified midwives in the
birthing experience of many Australian women'. The Minister is reported to have
stated that 'I recognise that a very small proportion of women would like to
have home births and am currently investigating if there is some way that we
can provide this as an option without making the proposed midwife indemnity insurance
unaffordable'.[30]
Collaborative care
1.40
The AMA commented that whether the legislation succeeds or fails will
depend on the requirement for the collaborative care models and the detail of
who will be responsible for the development, implementation and monitoring of
the models.[31]
The AMA also commented on the risks if care is fragmented. Dr Pesce stated:
If we do not get the arrangements right it will encourage
fragmentation of patient care, and fragmentation is the enemy of quality
healthcare delivery. We know that, as more people become involved in the care
of a patient, the risks of an adverse event increase significantly. This risk
is multiplied even further when you open up opportunities for other health
professionals to prescribe medications.[32]
1.41
The Rural Doctors Association of Australia (RDAA) voiced the opinion
that there is a significant risk associated with the authorisation of nurse
practitioner and midwife medication prescribing and ordering of diagnostics as
this could result uncoordinated and fragmented care and thereby increasing the
risk to the patients and cost to the government and community. The RDAA
commented that 'any arrangements that provide for nurses and midwifes to
provide additional services should manage this risk and ensure that the quality
of care provided to patients is improved and care is coordinated with the
patients' general practitioner'.[33]
Mr Steve Sant, RDAA, went on to comment that 'we strongly believe that the
general practitioner is the main provider and coordinator of medical care–I am
not saying health care; I am saying medical care'.[34]
1.42
The RDAA also voiced concern about the provisions in the legislation
which allow nurse practitioners and midwives to refer patients to medical
specialists without the patients being assessed by the patients' general
practitioner.[35]
Mr Sant stated:
The other problem with going directly to the specialist is
that you will end up with fragmentation of care. We already have big problems
with understanding and managing the totality of care that is provided to
patients. If we add another source which can be further fragmented, we are only
going to disadvantage our patients and cause them to incur additional costs,
and the Commonwealth will likely incur additional costs as well.[36]
1.43
In addition, Mr Sant commented that the midwifery services review
suggested that midwives should only be able to practise as part of a
collaborative team with either a general practitioner or a specialist
obstetrician, 'therefore we would argue there is no need for them to be able to
refer'.[37]
1.44
RANZCOG also commented that if RANZCOG Fellows are made to work in
collaborative care systems that they consider unsafe, a number of obstetricians
will cease to practice obstetrics, 'which could have significant workforce
implications for Obstetricians and particularly General Practitioner
Obstetricians in the country, who underpin the rural obstetric workforce'.[38]
1.45
The Committee received evidence in response to the matters raised by the
AMA and possible fragmentation of care. Mrs Wilkes, Australian Private Midwives
Association, commented to the Committee that care is already fragmented:
Frankly, I fail to see how maternity care in Australia can be
any more fragmented than it already is. The women who we care for talk to us
about having care from 10, 20 or 30 different people. Even if they engage a
private obstetrician, which gives them some security around who will attend
them in birth, they are still provided with in-labour care from a midwife they
have never met before, and that is if they are lucky and get one midwife.
Generally they will get more than one—three or four—and generally that midwife
will be caring for more than one person at any given time. The only way that a
woman in Australia today can guarantee that she will get the same midwife that
she has chosen to provide her with care from the beginning of pregnancy to six
weeks postpartum is to employ and pay for the services of a private practice
midwife.
1.46
The Australian Nursing Federation commented that the AMA's proposals
will not result in better care:
The ANF is of the view that involvement of doctors in the way
that is proposed [by the AMA] will indeed fragment care for the community.
Finding a doctor to merely rubber-stamp a professional decision is exactly what
we are trying to avoid in granting nurse practitioners and eligible midwives
access to the MBS and PBS. Nurse practitioners are educated, qualified and
regulated and operate under professional standards. They are well placed to
know when a doctor or specialist is required. Furthermore, should a nurse
practitioner refer, of course all interested and involved health professionals
will be forwarded the appropriate information regarding the referral and the
client’s progress. It is whoever the consumer sees fit to consult in relation
to their health care.[39]
1.47
Dr Barbara Vernon, Australian College of Midwives, also responded and
noted that the concern appeared to be that if, for example, a midwife has the
opportunity to refer a woman directly to an obstetric specialist, in line with
the evidence based guidelines, rather than referring the woman to her general
practitioner to make that referral, then the general practitioner will not be
in the pathway and will not understand what the woman's care involves. The
basis for this argument is that the general practitioner is the key coordinator
of care and therefore needs to be aware of the women's complete health details
even though she may not have chosen that clinician as her primary carer for the
maternity episode. Dr Vernon, however put the view that 'the evidence indicates
that midwives make safe and responsible decisions for engaging with GP
obstetricians or specialist obstetricians and that if you had a woman in labour
and something emerged where she would need medical input it is a nonsense to
think that we would build in some kind of additional layer of referral before
we could bring the doctor in to provide assistance to that woman'. Dr Vernon
concluded:
I think it is seen by some of the medical organisations as
being a thin-end-of-the-wedge argument—that if this arrangement was to apply in
maternity it might apply more broadly in health, and that would be of concern.[40]
1.48
Dr Vernon also commented on the importance of the discussions on the
design of the implementation of the bills as the bills set out only the
framework for the proposed changes. Negotiation will be required to ensure that
collaboration is 'built-in in a way that is going to facilitate good,
respectful working relationships between midwives and doctors' and are focused
on the needs of the individual women. Dr Vernon went on to comment:
It is not about captains of the team or who is in control; it
is about good communication, good exchange of information, mutual respect for
professional expertise and working alongside one another for the benefit of the
women. This is not about midwives substituting doctors or their providing care
instead of doctors providing care. Midwives have a scope of practice and
expertise in primary midwifery care. They recognise the scope of practice and
expertise of doctors. It is essential that the woman has seamless access to
both of those things as and when she needs it.[41]
1.49
In relation to prescribing, Professor Sally Tracy, Australian College of
Midwives, noted that midwives will be prescribing possibly 10 drugs and
commented:
...far less than is available in the chemist at the moment, and
something that midwives have been doing, and have to get signed off, every day
in their practice in the hospitals. It is just a bogyman, this idea that
ordering and prescribing drugs is going to get absolutely out of hand.[42]
1.50
The department responded to comments about the model of collaborative
care envisaged under the legislation. Ms Judy Daniels stated:
It is not the intention that these arrangements will be
highly prescriptive about the model of care that will operate. It will need to
be flexible to deal with different circumstances. That said, obviously—and you
have heard today—that a key underpinning of the package is a focus on
encouraging models of maternity care that involve continuity of midwifery care.
But the collaborative arrangements will need to ensure that effective
arrangements are in place for referral and escalation of care in circumstances
where medical need dictates, making sure that women have access to the
appropriate clinical expertise for the conditions that they have.[43]
1.51
In addition, the National Health and Medical Research Council (NHMRC) in
developing protocols and guidance as to how collaborative care could operate.[44]
Maternity Services Advisory Group
1.52
The Maternity Services Advisory Group (MSAG) is to be established with
representation from 22 key stakeholder organisations with an interest in
maternity care. The first meeting of the group took place on 12 August 2009.[45]
1.53
Witnesses commented that MSAG lacked a balance in its membership.
Homebirth Australia commented for example, that there no representation of
homebirth views.[46]
The Australian Private Midwives Association also commented that it was not
represented on MSAG.[47]
1.54
In relation to membership and the lack of representation of private
midwives, Ms Huxtable from the department commented that:
I believe that group was quite recently formed...It was a
question of balancing membership. There are two representatives of both the
Australian College of Midwives and the Maternity Coalition on the advisory
group. I would also say that the advisory group is one mechanism, and we do not
see it as the only mechanism by which consultation will occur. In fact, I think
that side by side with the advisory group will be technically focused working
groups where we will certainly be seeking to engage with others in respect of
the specific elements that are on the table.[48]
1.55
Ms Huxtable went on to note that it was anticipating that there would be
working group and technical group structures 'that will advance specific
elements of the package'.[49]
1.56
Ms Huxtable outlined the work of MSAG. The work undertaken was seen as
being in two phases: a scoping phase and then an actual development of
guidelines. In the latter, three items were identified:
-
the principles for collaborative maternal care including team
learning and review and how to ensure that maternity care is focused on the
woman in informing decision making and respecting choice;
-
protocols and referral procedures including how effective
information sharing and communication referral and consultation arrangements
that would underpin transfer of care are put in place, for example, emergency
transfers or emergency procedures; and how to undertake professional education
to support the collaborative care model; and
-
monitoring, evaluation and review of the practical operation of
the arrangements.[50]
Eligible midwife
1.57
In evidence, there was discussion around the use of the word 'eligible' in
the legislation with 'eligible midwives' having access to both MBS and
indemnity insurance. The Australian Private Midwives Association commented that
private practice midwives have not had input into the definition of
'eligibility' and that those midwives who fall outside the definition will be
prevented from private practice as they will be unable to secure the professional
indemnity insurance required to register. The Association therefore saw it as essential
that private practice midwives have equal opportunity to have input into
defining eligibility for their practice.[51]
1.58
Ms Huxtable, the Department of Health and Ageing, commented that in
relation to nurse practitioners there is the concept of an advanced
practitioner, however in the case of midwives there is the question of 'What is
an eligible midwife?' It was noted that work had commenced on the definitions
leading up to the budget announcements but 'we are really at the commencement
of the implementation and consultation mechanisms around nailing those ideas,
and that, as occurs commonly, will occur in very close consultation with the
profession'. MSAG is one of a number of mechanisms that will engage with
stakeholders around working on the definitional issues.[52]
1.59
Ms Huxtable went on to note:
On the question of eligible midwives, I think that there has
been a degree of consensus in our discussions to date with many of the
stakeholders that there are a number of factors that would come to bear in
determining what an eligible midwife is. That goes both to the level of
qualification and also to the level of experience of a midwife and there may
also need to be consideration about how to transition people who have a great
deal of experience in the field but who may not have the requisite higher
qualifications, and whether there is a way to transition them into the new
arrangements.[53]
Rural and remote area nurses
1.60
The RDAA commented on the exclusion of rural and remote area nurses from
the proposed arrangements. The RDAA noted that rural and remote areas nurses are
highly qualified and may have completed courses of study other than those
designed for nurse practitioners. While most remote area nurses do not hold
specific qualifications as a nurse practitioner, they practice in isolated
communities often with remote medical backup. The RDAA argued that they would
be 'ideal candidates to undertaken prescribing of medications and ordering of
diagnostic tests under the PBS and MBS'. By extending the ability to prescribe
and order a limited range of medications and tests, in accordance with an
agreed protocol, patients, who are often indigenous, would benefit. The RDAA
also commented that other groups of nurses who are endorsed by their
registration authorities and who have undertaken a course such as the
Queensland Accredited Rural and Isolated Practice Endorsement for Registered
Nurses Program, which enables them to prescribe in accordance with standing
orders or local protocol, should also have access to the PBS and MBS
arrangements. The RDAA concluded that 'unless these nurses are included in the
new arrangements little benefit will flow to rural and remote communities'.[54]
1.61
Ms Kerry Flanagan from the department responded:
No, I do not think remote area nurses are currently part of
this legislation. As I understand it, they have prescribing rights at the
moment under standing orders. But I do not think there was contemplation that
we would be looking at them...We are just looking at nurse practitioners and
midwives under this legislation.[55]
Prescribing group
1.62
In its evidence to the Committee, the AMA recommended that the
Government establish a new expert committee, the Health Profession Prescribing
Committee, to evaluate and advise on proposals to allow other health
professionals to prescribe pharmaceuticals.[56]
1.63
The department responded to the AMA's recommendation and stated that:
The natural development of advice to the PBAC [Pharmaceutical
Benefits Advisory Committee] will include the establishment of a group. If you
recall, with the optometrist measure there was definitely a process of going
through quite a deal of detailed discussion and investigation with stakeholders
about drawing up the lists of medicines that the PBAC would then consider. It
will be a similar process in this case.[57]
Indemnity for midwives
1.64
Indemnity cover for midwives was canvassed by a number of witnesses. The
Medical Indemnity Industry Association of Australia (MIIAA) raised a number of
matters in relation to the Midwife Professional Indemnity Bill. These included
the inclusion of a number of matters in Rules which are not yet available. The
MIIAA argued that some of the proposed Rules should be included into the Bill
as potential contracted insurers need to be able to understand the framework
that they will have to operate in and the risk to the contracted insurer of
Rule changes with the attendant risk of not recovering Commonwealth
contributions will be avoided.[58]
1.65
A number of matters were also raised in evidence by the MIIAA's
representatives including whether an eligible midwife 'who is deemed a
high-risk eligible midwife based on an abnormally high numbers of claims may
have imposed upon him or her a deductible or loading on their cover'. Mr David
Nathan, MIIAA, noted that such a right would encourage midwives to improve
their performance and stated that is the current position with medical
practitioners.[59]
Mr Nathan also noted that the scheme will insure an eligible midwife,
practicing in a manner that an eligible midwife is entitled to practice, but is
silent as to precisely what enables a midwife to be an eligible midwife or what
it is that an eligible midwife will do.[60]
1.66
In relation to insurance cover for homebirths, Mr Nathan stated:
...there is not a great deal of compelling data that one can
point to as to the relative risks of homebirths versus birthing centres and
versus this and that. The devil is often in the detail anyway as to whatever
data is available. The sense is that there is more risk associated with
homebirthing than there is in terms of the independent midwife model that is
being mooted as we speak.[61]
1.67
RANZCOG voiced concern that 'if midwives are indemnified, this could
lead to increased costs of indemnity for obstetricians as obstetricians may be
called in too late to manage an obstetric emergency and have to face the blame
for a poor outcome, when an earlier referral may have averted a crisis'.[62]
1.68
The exclusion of indemnity for private midwives undertaking homebirths
was also canvassed. Ms Caines of Homebirth Australia commented that indemnity
insurance is a professional requirement but also a consumer right.[63]
The Maternity Coalition commented that women and midwives involved in homebirth
have been unprotected by professional indemnity insurance since 2001. Midwives
working as employees (usually in hospitals) have been unaffected by this, as
they work under the cover of their employer. The reason for the withdrawal of
insurance cover was given as the small number of midwives purchasing cover. Maternity
Coalition went on to state that it is 'unaware of an evidence-based discussion
on the cost of insurance cover for homebirth midwifery...It is unclear whether
advice provided to Government is rationally informed by a good understanding of
midwifery practice and the risks around homebirth.'[64]
1.69
Dr Vernon, Australian College of Midwives, indicated to the Committee
that insurers had not provided indemnity for midwives as 'the pool of midwives
who would seek a policy has been relatively small and they have therefore seen
that that pool has not been large enough for them to make it commercially
viable to potentially cover off on a $12 million payout, which was the Calandre
Simpson case'. Dr Vernon went on to comment:
We have been hopeful that the government's commitment to
extending Medicare benefit schedule access to private midwives would, over
time, create a larger pool of midwives seeking a policy and that that
commercial barrier would be removed. That possibility was ruled out when the
legislation indicated that it would not be an option for midwives to provide
care at home. Our preference is to see that the location of care is not the
primary driver. We do not have insurance policies for doctors that stipulate
the setting in which they must provide their care; the insurance cover is
related to their qualifications, their scope of practice and verification of
that by their professional organisations.[65]
1.70
Dr Vernon also stated that insurers have indicated that they do not have
profound concerns about the safety of midwifery care. Rather:
What they are telling us is that they are unsure from the
documentation the government has currently provided as to what it is that they
are being asked to tender for. They are talking particularly about the lack of
information at the moment about eligibility—which midwives would provide this
care—and there is no information about the collaboration and how that will
occur between midwives and doctors and between midwives and hospitals. So they
see it very much as the cart before the horse and they are puzzled why it is
that the process at the moment is trying to drive the preparation of a request
for tender from insurers ahead of those things being worked out.[66]
1.71
The Australian College of Midwives suggested that further consultation
with private practice midwives and the College needs to occur to identify the
care provided by private practice midwives in the home and to determine the
types of risk involved. The College went on to argue that there are significant
differences between midwifery and obstetric care with obstetric care involving
major surgery, induction of labour and use of epidural anaesthesia. These procedures
involve substantial risk but midwives providing care in the home do not perform
any of these interventions. The College concluded that 'the actual risk of
unpredictable, catastrophic events in the absence of other interventions would
need to be examined in the context of healthy women with (generally)
uncomplicated pregnancies, in well networked and collaborative systems of care'.[67]
1.72
The Australian Private Midwives Association also called for further
consultation on indemnity and stated that the risk profiles should be properly
examined. Ms Wilkes commented:
None of these has really been well explored. Well, if it has
all been well explored it has not been well explored in consultation with those
that are working in private practice. It may have been explored by somebody
somewhere along the line but we do not know about it, but if only we could
actually actively engage on that and see what that looks like and see what the
sorts of insurance products look like and at least do cost comparisons and see
whether it is a cost thing and whether it is a safety thing and what the
mechanisms are.[68]
1.73
The department's representatives explained the process for the insurance
tender to the Committee. The department will conduct a tender process which
will select an insurer who is the insurer who offers the policies which are
supported by the Commonwealth. A significant range of technical detail will
appear in the tender documents and in the contract with the selected insurer.
The department noted that many of the technical issues raised by the MIIAA will
be answered in the course of the tender process. The policy offered to midwives
will cover the scope of their practice.
1.74
Professor Rosemary Calder concluded:
...the intention is that, as we work towards identifying the
insurer that is appropriate for this, we will also be working on the issues
around eligibility, noting that it is initially defined by registration and
scope of practice. That is an assurance to the insurance industry of where this
will go and that, as it reaches the point where insurance products need to be
developed, the eligibility criteria will have firmed up.[69]
Conclusion
1.75
The Committee welcomes the initiatives contained in the three bills. The
recognition of the professional skills and expertise of nurse practitioners and
midwives is a significant step. In particular, the changes to allow these two
groups of professionals to access the Medicare Benefits Schedule and
Pharmaceutical Benefits Scheme will strengthen the health system and the
delivery of maternity services in Australia.
1.76
The Committee notes that these three Bills do not take away any current
rights and none of these Bills make homebirth unlawful.
1.77
The Committee notes that there is a separate exposure draft Bill for the
National Registration and Accreditation Scheme for Health Professionals which
has been prepared for all jurisdictions via a COAG agreement. It is the outcome
of this legislation that may result in homebirths being outside the scope of
practice of registered midwives due to the requirement for indemnity insurance
as a condition of registration. The Committee acknowledges the concerns
expressed by stakeholders that an unintended consequence of this may be to
drive homebirths underground unless an exemption is granted or an insurance
product found.
1.78
The Committee acknowledges that the minister is currently working with
the States and Territories on potential options to prevent this from happening.
This will include investigating indemnity options for homebirths that could be
progressed without making the insurance unaffordable.
Recommendation 1
1.79
The Committee recommends that the Health Legislation Amendment (Midwives
and Nurse Practitioners) Bill 2009, the Midwife Professional Indemnity
(Commonwealth Contribution) Scheme Bill 2009 and the Midwife Professional
Indemnity (Run-off Cover Support Payment) Bill 2009 be passed.
Senator Claire Moore
Chair
August 2009
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