Wednesday, 16 October 2019
Medical and Midwife Indemnity Legislation Amendment Bill 2019; Second Reading
I'm very pleased to rise to speak on the Medical and Midwife Indemnity Legislation Amendment Bill 2019 and the second reading amendment. It's quite rare in this place to rise to speak on legislation in which one has a very particular interest. I can say without much hesitation that this legislation is of great interest to me. I have personal involvement. I still practise as a paediatrician. Even though I raise no income from that, I have to pay medical indemnity insurance because I'm still seeing patients. It is a significant cost. Over my 40 years in practice I have seen a huge change in medical indemnity costs. When I first started in my private practice, my medical indemnity fees rose to $250 a year. When I was working as a doctor only in the public health system, I paid $100 a year. I can remember being quite annoyed that my medical indemnity insurance rose from $100 and more than doubled to $250 a year because I started a private practice and was still working in the public hospital system.
Since that time we've seen an explosion in medical indemnity costs. The reasons why those costs should have increased so hugely are not completely clear even now to me, but they've now risen to the point where they have a significant influence on medical practice across many specialties and are altering the way young doctors are entering practice. For example, in my field of paediatrics we have quite large medical indemnity costs because the lag time where people can take legal action against you is so long. The normal statute of limitations is seven years. But, because the age of majority is 18, people can take legal action against paediatricians for up to 25 years after birth, so it's a huge lag time, which increases the premiums. When I was in private practice, before entering politics, my medical insurance costs were over $30,000 a year. That has a significant influence now on young paediatricians as to whether they go into private practice, combine private and public practice or work exclusively as staff physicians in public hospitals, where their medical indemnity costs are paid by the state government.
What we're now seeing is a huge disincentive for people to enter private practice. That has a really major effect on patients' ability to access paediatric care and see paediatricians, because the fewer doctors in private practice the bigger the burdens put on the public hospital system. The public hospital outpatient clinics are often poorly staffed and poorly funded, so people may only do one or two clinics a week in public practice, compared to daily clinics in private practice. So it is already affecting the way people practise medicine and the type of practice they start.
That's true in paediatrics. It's very true in the other specialties that have high medical indemnity costs—in particular, neurosurgery. Many people are reluctant now to go into private neurosurgical practice and prefer to stay working in the public hospital system. Those who do go into private practice are forced to charge extremely large gap fees to at least partly cover their insurance costs. So it is affecting access to neurosurgical care.
Of course, there is a big difference in obstetrics. When I started my training as a medical student, the vast majority of obstetricians worked in private practice, even though they also practised in public hospitals. The change in medical indemnity costs in the eighties and nineties has meant that most obstetricians going into practice now are going into fully paid staff obstetrics jobs in the public hospital system; they're not entering private practice. That limits the options available for women who are pregnant to access obstetric care, and once again the burden has fallen back on the public hospital system to cover all those costs and to cover those women.
In the public hospital in Campbelltown where I worked, for example, we have a rapidly increasing population, which is rapidly ramping up demands on our obstetrics services. We now do 4,000 deliveries a year, which is really a very big number, increased from about 2,000 10 years ago. The numbers are increasing, and there are very few obstetricians now in private practice. When I started at Campbelltown in 1984, there were eight obstetricians in private medical practice and there was one staff obstetrician. There are now eight staff obstetricians and only two obstetricians in private practice. At least a significant part of that change has been due to the rapid increase in medical indemnity costs.
The other issue in obstetrics we're now facing is that—while we have midwives in private practice who are now at least able to access medical indemnity insurance, and that is a very good thing—increasingly, particularly in outer metropolitan, rural and regional areas, a lot of the obstetric care load is being placed on the midwives rather than on obstetricians, and many of the GP obstetricians in country and regional areas have been forced out of practice because of the high medical indemnity costs. So we're seeing a whole change in medical practice. More and more women are being forced to deliver in the major hospitals and can't deliver in their local hospitals. That has a significant impact, particularly on Indigenous people, who much prefer to give birth on country—it's very culturally and spiritually important for them, and it is being denied to them. At least private midwives are now able to access medical insurance, and that will help in rural and regional areas. But, because of the cost of insurance, it does nothing to help those GP obstetricians to set up practice, and fewer and fewer general practitioners in rural and regional areas are opting to include obstetrics. I think that's a very sad thing, and I think that it is putting more and more pressure on our public hospital system. We are seeing a huge ramp-up in women accessing obstetric care in the public hospital system and fewer and fewer women being able to deliver in their local hospitals in rural and regional areas because of the lack of access to GP obstetricians.
I think it's a very good thing that our midwives can now access private medical insurance, and I hope to see more and more midwives enter private practice, because we certainly need them and, for uncomplicated pregnancies, they're a very good care model. Shared care models are also very good. But, once again, our medical insurance costs are limiting the ability of GPs and obstetricians to go into private practice, thus limiting the options for many people in rural and regional areas.
This is also true in my own specialty of paediatrics. More and more paediatricians in rural and country areas are opting for staff jobs rather than private practice jobs. One thing we know about private practice is that it copes with volumes of patients very well, much more efficiently than the public hospital system. And we see that, in rural and regional areas in New South Wales, Queensland, Victoria, Western Australia and South Australia, and even in Canberra, it is harder and harder for people to access paediatric care, because waiting lists for the public hospital clinics, if they do exist, are blowing out further and further.
So, whilst we do support this legislation, it does nothing very much to improve the access to care in obstetrics and in many other specialties in many areas of the country, and the problem is only going to get worse. More and more doctors are opting for fully paid staff jobs. At the same time, state governments—and I include the New South Wales government in this—are intent on reducing the number of outpatient clinics being provided, so the waiting lists are blowing out further and further. In some areas, I believe, waiting lists for public outpatient clinics are now measured not in months but in years. I know also that in some hospitals, including my hospital, some specialties no longer have public outpatient clinics.
So it's a sort of double whammy. The increasing insurance costs are forcing doctors to stay in the public hospital system, with fully paid salaries, and state governments are reducing funding for public outpatient clinics, so more and more people are being forced into these public outpatient clinics but the waiting lists are getting longer and longer. People are even being forced to go out of area to some outpatient clinics because their local hospitals don't actually have clinics in certain specialties, such as cardiology, neurology, neurosurgery et cetera. At my hospital, the waiting time to get into the obstetric outpatient clinic has blown out, so many people are not having their first visit to the obstetric clinic until after 14 weeks gestation, which is also limiting their ability to maintain a healthy pregnancy, to get early imaging if there's any concern about the foetus or any treatment that may well be needed. Whilst improving the number of midwives able to access medical indemnity insurance may help individual midwifes, it's going to do very little in the public hospital system, particularly in obstetrics and in other specialties. Whilst we support this legislation, it's going to do very little to keep premiums down, it's going to do very little to encourage people into private practice, and it's going to do very little to improve public hospital waiting lists.
Very quickly, I'd also like to say one thing about homebirths and about midwives attending homebirths being able to access private medical insurance. I personally do not like the concept of homebirthing. I think it puts the mother and also the baby at risk because obstetrics is a trial of life, and it's not always immediately obvious whether a pregnancy is going to be a troubled pregnancy with a difficult delivery at the end. It's not always obvious. My grandmother died during childbirth. I know that even with the best assessments it's still a risk, so I prefer babies to be born in hospitals, where they have access to acute resuscitation if needed. What we want from every pregnancy is a healthy baby and a healthy mother. However, having said that, some people these days do want a homebirth, and they're insistent upon it. If that's their choice, there's very little that I can do to stop them. And, if that is what they want, then they should be able to access the best support they can with a midwife at home. I strongly believe that we should be providing indemnity insurance for those midwives who want to do homebirths, because that's what people choose. If that's what they choose, they should be able to access the best possible care. This legislation does not provide for that, and I think that it would be very important if that could be considered, because people's choices don't mean that we shouldn't provide them with the best possible care.
This is a piece of legislation that I have a very personal interest in, and I commend the bill to the House.