House debates

Wednesday, 16 October 2019


Medical and Midwife Indemnity Legislation Amendment Bill 2019; Second Reading

10:04 am

Photo of Chris BowenChris Bowen (McMahon, Australian Labor Party, Shadow Minister for Health) Share this | | Hansard source

The Labor Party will be supporting the Medical and Midwife Indemnity Legislation Amendment Bill 2019, which seeks to improve the operation of indemnity insurance following a first principles review. This is a very important item and I note that this bill does go some way—but only some way—to addressing some problems in the current environment for Australia's midwives. The requirement that all indemnity insurers must provide cover to all providers who need it is a particularly useful provision in this bill. At present this universal cover obligation only applies to the four insurers who have contracts with the Commonwealth. This is a sensible extension which will help.

I want to place on record my thanks to all the doctors, midwives, pharmacists and others who've contributed to the review process that has led to this legislation. We do support this legislation but I need to note that this will be an ongoing problem. This legislation does not fix some of the fundamental issues facing Australia's midwives. There are big gaps in indemnity insurance for Australia's midwives, and this legislation does not even attempt to deal with those. There are two major issues with midwifery indemnity insurance that it does not address: the lack of cover for homebirths and the lack of competition and choice in other midwifery cover.

There's only one provider for indemnity insurance for midwives, which means there is absolutely no competition in the market. The lack of competition—I freely acknowledge—is not an easy issue for the government to fix, but it is one the government should pay some attention to and should be trying to think of creative solutions for. The other issue is that there is no indemnity insurance for all homebirths. While there's an exemption for holding that insurance, it is set to expire, which, of course, creates massive uncertainty for midwives in relation to homebirths. This is not a sustainable situation, and the minister does need to be turning his attention to this issue. Ultimately, it could jeopardise the ability of midwives to attend homebirths. Parents should have a range of choices when considering their birthing options. One of those choices is to have a midwife attend a homebirth, but that may not be the case if the exemption is not extended or if there's not a solution found for the lack of indemnity insurance, because then midwives will have to respond accordingly to the risk.

Our concerns about these issues are consistent with our longstanding support for midwives. It's important to remember that the last Labor government added midwives to the national registration scheme, which was a very important initiative in recognition of their professionalism and their importance in the health system. We ensured that regulations are on par with other medical professionals, as they should be. It also gave midwives access to a range of Medicare and PBS items for the first time.

I was very pleased to attend the conference of the College of Midwives a few weeks ago and to address some of these issues at their important conference in Canberra and to express my support for midwifery and the roles they play in supporting new parents across the country.

I now move:

That all words after “That” be omitted with a view to substituting the following words:

“whilst not declining to give the bill a second reading, the House calls on the Government to address the lack of indemnity insurance for midwives who attend home births, as well as the lack of competition and choice in other midwifery cover”.

This amendment will give the House an opportunity to express its concerns about these issues. We don't pretend they're easy. This has been an ongoing issue for Australian midwives since 2002, when a major provider went bankrupt. Midwives deserve the support of the government of the day, and they deserve the attention of this House. So we call on the government to provide more attention to these issues.

Photo of Rob MitchellRob Mitchell (McEwen, Australian Labor Party) Share this | | Hansard source

Is the amendment seconded?

Photo of Ms Catherine KingMs Catherine King (Ballarat, Australian Labor Party, Shadow Minister for Infrastructure, Transport and Regional Development) Share this | | Hansard source

I second the amendment.

10:09 am

Photo of Susan TemplemanSusan Templeman (Macquarie, Australian Labor Party) Share this | | Hansard source

I rise to support the Medical and Midwife Indemnity Legislation Amendment Bill 2019 and the amendment moved by the shadow health minister. This issue did have its start in the major market failure that occurred in 2002 and which impacted midwifery indemnity insurance. Since then, various reviews have determined a way forward. I note the involvement of stakeholders like the College of Midwives, the Australian Nursing and Midwifery Federation and the Australian Medical Association, who are all supporting the fact that there is now action on this issue. I thank them for engaging in the process; I know it has been a long one.

There are two unresolved issues in the midwifery indemnity insurance area. They both have an impact on midwives and, therefore, on women who seek to had a midwife at their birth and in particular at a homebirth. In my electorate of Macquarie a significant number of families choose to have a homebirth. That is their preferred option. The first unresolved issue is the lack of indemnity insurance for midwives who are doing homebirths. Midwives delivered both of my children. I didn't choose to have a homebirth, but we need to respect the right of women who want to go down that path and ensure that they have the support they need to do that, and that means having access to midwives. When midwives can't access insurance, the process becomes harder and riskier. That may well happen if the current exemption expires and there is no further action on it.

In Australia about 0.3 per cent of births are planned homebirths. That compares with two or three per cent in Britain, up to five per cent in New Zealand and around 13 per cent in the Netherlands. That shows that, where there is support, there are women who choose this option—women like Aimee Sing, a consumer advocate with Homebirth Access Sydney and a part of the Blue Mountains homebirth community. She is a fierce advocate for this matter. She is keen to see any barriers to women choosing a homebirth—if that is their preference—come down.

I also note that there have been calls recently from midwives and homebirthing groups for a Medicare rebate to be applied to homebirths. The minister has advised that the Medicare Benefits Schedule Review Taskforce will submit its findings on that matter before the end of the year. I look forward to that.

I also note that this bill doesn't provide for any choice of insurer for midwifery cover. There is a monopoly; there is just one provider. Again, we are really limiting the choices for midwives. My concern with that is that it flows through to the choices that women have. They need to make decisions that are in their best interests, their family's best interests and their unborn child's best interests.

I urge the government to address those issues. This really is about women having the ability to make choices about where and with whom they give birth. It's a very individual decision. What determines that decision shouldn't be insurance considerations.

10:12 am

Photo of Mike FreelanderMike Freelander (Macarthur, Australian Labor Party) Share this | | Hansard source

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.

10:27 am

Photo of Julie OwensJulie Owens (Parramatta, Australian Labor Party) Share this | | Hansard source

I was reminded when preparing to speak today of the number of people in my electorate who have contacted me over recent years with a great passion for midwifery—midwives, who were looking at ways to improve indemnity for themselves and create more choice for mothers; and mothers, who were looking for homebirths or stronger relationships with midwives.

The area that we're talking about today, the indemnity of medical professionals, is one which has had bipartisan support for a long period of time. I'm going to talk a little bit about the history of medical indemnity, particularly since about the year 2000. I'm aware that the former health minister is sitting at the table down the front, so if a small piece of balled-up paper heads in my direction and you see it fly and hit me, it's because I've got something slightly wrong—or terribly wrong! I'm sure she'll correct me. Way back before 2010, there were no obligations for nurses or midwives to have professional indemnity insurance as a condition of their registration or practice. Indemnity insurance arrangements varied significantly. Midwives who were employed in public and private sectors were indemnified under their employer's insurance policies, usually as part of their employment relationships. Prior to 2001, midwives could purchase their own private indemnity insurance through membership of industrial and professional organisations, such as the Australian Nursing Federation and the Royal College of Nursing Australia. But in 2000-01 professional indemnity insurance coverage was withdrawn from midwives engaged in private practice, and this decision was considered to be in response to the perceived medical indemnity crisis of the late 1990s. Between 2001 and 2010, insurers did not offer professional indemnity insurance to midwives in private practice at all. Commonwealth medical indemnity laws, intended to ensure the affordability of professional indemnity cover across Australia, did not extend to midwives.

In 2002 Australia's largest medical indemnity insurer was placed in provisional liquidation. This liquidation would've left 60 per cent of medical providers without cover, meaning their patients may not have been compensated for medical negligence. In response, the Howard government established what is now known as the Indemnity Insurance Fund. The IIF is made up of seven separate schemes to promote stability in the medical indemnity insurance market and ensure affordable cover for private doctors and midwives. The Howard government's intention was to phase out the scheme over time as the medical indemnity insurance market was normalised. There were reviews in 2014 and 2016, and the government committed to the first principles review in the 2016 MYEFO, which also included savings of $36 million. But the review reported in 2018 and recommended that, in spite of John Howard's view that this would be phased out over time, it should actually be maintained. But, as I said earlier, midwives in private practice were not covered by that scheme.

In June 2008 the Rudd government undertook a national review of maternity services in Australia. The report, Improving maternity services in Australia: the report of the Maternity Services Review, was released in February 2009. It examined a range of issues, including the safety and quality of maternity services; women's access to a range of models of care; inequality of outcomes and access; information and support for women and their families; and financing arrangements. The review noted that there were a number of financial restraints on private service delivery by midwives, which acted as a barrier to increasing the range of models of maternity care available in Australia and therefore limited women's choice. Such constraints included the lack of access to professional indemnity insurance. The review examined the reasons for this, noting:

It is difficult for insurers to come up with a suitable premium for midwives because the provision of birthing services by privately practising midwives is perceived to be a high-risk activity. No adequate and reliable data is available to develop an accurate risk profile for privately practising midwives who provide birthing services. Accordingly, midwives operating privately in Australia who wish to provide the full range of maternity services are currently not able to do so with the protection of professional indemnity cover.

The review also found that, as a consequence, midwives providing support for birthing privately were doing so at their own financial risk, or, depending on the midwife's financial circumstances, the risk was being transferred to the client, who would have no recourse to compensation. It further found that a lack of professional indemnity cover was a barrier to the development of collaborative models of maternity care involving privately practising midwives. The report noted that the planned introduction of the health profession's National Registration and Accreditation Scheme would pose problems for privately practising midwives, who would not obtain the professional indemnity insurance required for registration under state and territory laws. It recommended that, while a risk profile for midwife professional indemnity insurance premiums is being developed, consideration be given to Commonwealth support to ensure that suitable professional indemnity insurance is available for appropriately qualified and skilled midwives operating in collaborative team-based models. Consideration would include both the period and the quantum of funding.

In response to the Maternity Services Review, the government announced a $120.5 million package of maternity measures in the 2009-10 budget. The measures included giving access to Medicare Benefits Schedule and Pharmaceutical Benefits Scheme benefits for certain services provided by midwives for the first time, as well as providing government supported professional indemnity insurance for midwives.

The laws that were introduced enabled the Commonwealth to meet part of the cost of large settlements or awards paid by eligible insurers that indemnify eligible midwives, including meeting the amounts by which such payments exceed the insurance contact limits, and to provide ongoing insurance for eligible midwives who have ceased private practice—remembering, of course, that claims can be made for past medical services, so the liability of a midwife does not cease when the midwife ceases to practice.

The Commonwealth has also moved to contract with an insurer to provide an affordable professional indemnity insurance product to certain midwives, and in May 2010 announced that this would be provided by Medical Insurance Group Australia. That insurance has been available through MIGA since 2010. However, as discussed previously and by previous speakers, this insurance did not cover the planned delivery of babies in the home.

Now we come to this bill, the Medical and Midwife Indemnity Legislation Amendment Bill 2019—which is a good bill and Labor supports it. This bill goes some way to addressing some problems in the current environment. The requirement that all indemnity insurers must provide cover to all providers who need it is particularly useful. At present, this universal cover obligation only applies to the four insurers who have contracts with the Commonwealth. So that's really a very good thing.

I would like to thank all the doctors, midwives, pharmacists and others who contributed to the review process under the current government and the outcomes that have been achieved, but there are still some gaps that this bill does not address. It does not address two major issues in midwifery indemnity insurance: firstly, the lack of choice in midwifery cover. There's only one provider for indemnity insurance for midwives, which means that there is no competition in the market—but it is great that there is one. Again, this is due to work done on both sides of the aisle in a bipartisan manner. Without the histrionics and fist-waving that sometimes surrounds policy areas, this one has been quietly worked on by both sides of government for a long time, and much of the work that has been done is really good. But there are always gaps and there are always ways to make improvements. The lack of competition isn't an easy one for any government to fix, but it is one that government should play a role in and have attention to fixing. I look forward to both sides of the House working to find solutions to that.

The other issue is that there is still no indemnity insurance at all for homebirths. While there's an exemption for holding that insurance, it is set to expire at the end of 2019, which creates massive uncertainty for midwives in relation to homebirths. And, again, it prevents some of those collaborative models that we might see grow if there were better protection for mothers and practitioners.

Labor's concern about these issues is consistent with our longstanding support for midwives. It is important to remember that the last Labor government added midwives to the National Registration and Accreditation Scheme and ensured that the regulation was on par with other medical professions, as of course it should be. We also gave midwives access to a range of Medicare and PBS items for the first time.

Those two weaknesses that I mentioned in the current law also create a third one, which is a lack of midwives. We are seeing around the country some major midwifery services closing because of a lack of midwives. Without certainty, without indemnity and without the protections that other healthcare professionals enjoy we will not see the growth in this sector that we should see. That would be a shame, because choice for mothers, alternative models and new approaches are welcome as long as they are undertaken with the appropriate safety protections in place.

This is a good bill, and I'm pleased to have spoken on it. It will do a number of good things. It will require all indemnity insurers to provide cover to all providers who need it. It will increase the maximum risk loading for providers with poor records to 200 per cent of average premiums and allow insurers to refuse cover in exceptional circumstances. It will establish a separate high-cost claim scheme for all allied health providers, including midwives. At present, there is a separate scheme for midwives but some pharmacists are inadvertently covered by the medical scheme. It will streamline the legislation that covers the schemes and it will require an actuarial assessment of the medical indemnity market to be tabled in parliament by February 2001. The bill's major provisions will take effect on 1 July 2020, following the tabling of detailed regulations on which the government is currently consulting widely.

I don't have anything more to add except to remark once again that it is good to see the quality of work that can be done in this House when governments and oppositions do not run at each other chest forward; when we work quietly through our committees and through consultation processes to get good results. There is still a way to go, but this is a step in the right direction.

10:40 am

Photo of Helen HainesHelen Haines (Indi, Independent) Share this | | Hansard source

I thank the member for Parramatta for the comments she has just made. I'd like to add my voice to the discussion on this bill, the Medical and Midwife Indemnity Legislation Amendment Bill 2019. Firstly, I congratulate Minister Hunt on this bill, which has the full support of the AMA, the Australian College of Midwives, the Australian College of GPs, and respective allied health and midwifery leaders. And I very much support the amendment that has been put forward by the member for McMahon and was spoken to just now by the member for Parramatta.

This bill addresses a key problem that is occurring in our maternity services, and I'm very pleased to see that this problem is being addressed. It's so important to ensure that Australian women have access to the highest quality of maternity care. We know that the highest quality of maternity care has the woman in the right place at the right time with the right health professionals, and we know that the right health professionals are a blend of midwives, obstetricians and allied health professionals. This bill helps us to undertake the work that is required to remove what was a systemic barrier for midwives in particular to accessing the indemnity insurance that they needed in order to practise to the full capacity of their scope as a midwife in private practice.

This is really important because what we need are models of care in our maternity system that allow choice for women. When we have choice for women, we give women control of their immediate circumstances. When we have choice for women, we allow them to see practitioners in addition to the traditional model of medical care that has largely been available in our health system. One of the things that we know about midwifery care—and I speak on this with some passion, as I practised as a midwife for more than 20 years prior to undertaking an academic career—is that midwives are frontline public health practitioners. Midwives are the people who introduce women to the essential public health aspects of vaccination, breastfeeding and early parenting whereby the most essential parts of a person's life are set up. We know, in fact, that the most essential determinants of a person's future health are set up during pregnancy and the early parenting period. Midwives play a key role in ensuring that women enter their pregnancy, give birth and then establish early parenting with their front foot forward. So I am really pleased to have the opportunity to speak to this bill in the House.

I really want to highlight today the importance of the role of the midwife, including the ways that midwives work in continuity-of-care models. That includes private practice and, indeed, homebirth, which is a part of private practice. I want to draw the attention of the House to the Cochrane systematic review of midwifery practice that was undertaken with more than 12,000 people. It showed very, very clearly that, when we have a midwife engaged in the care of healthy women, we have significant improvements to women's health. There are significant improvements that reduce the number of fetal deaths. Something that we were marking in this House yesterday was the reduction of stillbirths in our population. The Cochrane review indicated that when we have midwives leading the care of women we have a significant reduction in those deaths—in fact, 12 per cent. That's a very, very important thing.

What's also important is that, when we have midwives leading the care of women in collaboration with their medical colleagues, we reduce the numbers of operative births and we reduce the number of instances of regional anaesthesia that are required during childbirth, and, when we do that, of course we reduce the morbidity that women experience. That is extremely important to the broader health system and the ongoing care of our women.

Removing a structural barrier to accessing full insurance coverage is so important, and so is fostering models of midwifery care that can be useful in rural communities such as where I live. It is a clear signal to midwives that this government takes their role very, very seriously, and midwives need that clear signal. Right now in my electorate, we have severe workforce shortages in our rural midwifery workforce. In fact, Australian Institute of Health and Welfare data from 2017 shows that in major cities we have 16 midwives to every 100,000 people. In inner regional and outer regional areas, that number falls to six.

In Yarrawonga, right next door to my electorate of Indi, the health service announced last week that they will be closing the maternity services come January 2020. The reason for that is they have no midwives. That means that the GPs in that town have no midwives to support them either. This is a symbiotic relationship. Midwives and GPs in rural areas work hand in hand. Midwives and rural obstetricians work hand in hand. With the loss of maternity services in Yarrawonga comes pressure on my home town of Wangaratta, a regional health service which itself is experiencing an extreme shortage of midwives. Right now they're paying exorbitant amounts of money to bring in agency midwives from Melbourne to staff the maternity wards. That puts enormous pressure on the health service, it puts enormous pressure on the longer-term midwives and it puts enormous pressure on the obstetricians who are taking care of those women. So I'm really concerned about that. We know that without midwives the quality of care for both healthy women and women at medical risk becomes something that is not optimised. A bill such as this gives a clear signal to midwives that they're valued in the system, and I really appreciate that.

I would particularly like to highlight today the role of midwife led models of care and I had the opportunity to mention this to Minister Hunt a few weeks ago. A midwife led model of care is a continuity model, in which a woman gets to meet a midwife right at the beginning of her pregnancy and that midwife, and a small group of backup midwives, looks after her throughout her pregnancy and throughout the birthing period and perinatal period. This is incredibly important, because the international research is very clear that, when a midwife is known to a woman, all aspects of her care are improved. Most importantly, her satisfaction with care is improved. I've done substantial research around fear and anxiety in childbirth, and the one thing that we know in reducing a woman's fear, anxiety and subsequent perinatal mental distress—and indeed perinatal anxiety and depression—is if she has confidence in the care that she is given. So this is extremely important.

Again, bringing it back to my electorate of Indi, I'm very proud to say that in my early days as a midwife there I was part of a team that established a continuity of midwife care model called the Wangaratta community midwife care program. It's the longest-running rural continuity of midwife care program in Australia and it recently celebrated its 20-year anniversary, which I was very proud to attend. I pay tribute to the midwives who have continued to offer that model of care. That model of care can be enhanced by a bill such as this, because it means that privately practising midwives who are not part of the traditional model that generally operates out of a hospital can work in a model such as this with the full security of indemnity insurance. Perhaps some of midwives who are no longer able to work in Yarrawonga can now register as privately practising midwives and join that program in Wangaratta, to offer the care that is no longer available in Yarrawonga and to have the backup of services of the Wangaratta hospital.

So a bill such as this is very practical and useful. But I would add my voice to that of the member for Parramatta and say that the bill could go a bit further and ensure that homebirth services are also included in this—homebirth services that are backed up by the Australian College of Midwives, with all of the quality assurance that goes with the registration required to be a homebirth midwife. Homebirthing is not something that most women want. It's something that some women want. Some women want it because they’ve been disenfranchised by the traditional models of care. I think that that, if this bill was able to include midwives in private practice offering homebirths, that would be a very welcome addition to a small but significant number of women.

That small number of women includes some women who undertake freebirthing, birthing without a midwife or a medical practitioner at all, because they're too afraid to go to a hospital. That's a small number of women, but, significantly, those women are at great risk of incurring problems to themselves and their baby. Wherever possible, of course, we want women to have the care of a fully professional midwife with all of the training and skills that they bring. As I said before, the Cochrane systematic review on midwife-led models of care has significant advantages for women, and I am very pleased that I can stand here as a midwife and support this bill.

In addition to normalising and humanising birth, the contribution of midwives to the quality and safety of health care is absolutely substantial. And the contribution that we in this House, as policymakers who really wish to improve maternity services, can make is substantial. Any way that we can remove systematic barriers to having the best possible team looking after the women in our care in the public health system is extremely important. This bill contributes to the opportunities that we can create across our health system, and I support this bill wholeheartedly, with the addition of this amendment if we can possibly come to some agreement on that.

That's really all I want to say today about this. As a midwife, as someone who has practised substantially in this field, and as someone who still has very strong links into the rural community of Indi, where I'm very privileged to be the member, I want to point out to this House that the midwifery workforce is currently under enormous stress. Anything that we can do to provide financing, increase the numbers of midwives trained in our rural areas and increase the opportunities for midwives from the city to consider a career in rural health services would be most welcome, and any way that we can contribute to increasing the choices that women can have as they approach the most important period of their life—giving birth to a baby and early parenting, including breastfeeding and all of the aspects of public health—is extremely important.

The final thing I want to say is that a midwife's role goes beyond even that. The public health role of midwife, including the role that they can play in women speaking to them of domestic violence and in putting in early intervention around aspects of family life that can increase the likelihood of a small child having a higher quality of life, is incredibly important. So I add my voice to those others in the House today to commend the minister for this bill, to commend the collaboration that's happened across the aisles and to commend my colleagues in medicine, midwifery and allied health for their collaboration in drafting this piece of legislation.

10:52 am

Photo of Ged KearneyGed Kearney (Cooper, Australian Labor Party, Shadow Assistant Minister for Skills) Share this | | Hansard source

I rise to speak to the Medical and Midwife Indemnity Legislation Amendment Bill 2019. Labor too supports this bill, as it helps to ensure stable premiums for providers and therefore makes their services much more affordable for their patients. By requiring all indemnity insurers to provide cover to all practitioners and providers who need it, instead of just the current four insurers who have contracts with the Commonwealth, our community, including birthing families, will have more choice. Having more players in this field will also increase competition amongst the insurers, which, hopefully, means that premium prices are actually competitive and kept lower. The scheme establishes separate high-cost claim schemes for allied health providers, including midwives, with an important review of the medical indemnity market to be done by February 2021 following the introduction of the bill on 1 July 2020.

I understand there is still consultation with stakeholders on the detailed regulations, and that is important because this bill does not address two major issues: there is a lack of cover for midwives for home births, and there is a monopoly held by the only provider of midwifery insurance cover. In 2002, Australia's largest medical indemnity insurer was placed in provisional liquidation, and this would have left 60 per cent of medical providers without cover, meaning their patients might not have been compensated for medical negligence. So the Indemnity Insurance Fund was set up by the Howard government. It made insurance more affordable for private doctors and midwives who work predominantly in public hospitals. The scheme has been reviewed, but the review recommended that it should be maintained, and the changes we see here with this bill are a result of that review.

In a past life I had the privilege of being a nurse and working very closely with midwives. I listened intently and with great interest to the previous speaker, the member for Indi, who of course is well known in this area and admired for her work. I'd like to acknowledge that.

At the Australian Nursing and Midwifery Federation where I worked, we had a great relationship with our midwifery members, and I worked very closely with the College of Midwives, who have long been advocating for midwifery led care. Midwives and nurses, as we know, are among the most trusted people in our community. We have heard from the member for Indi how outcomes for mums and babies are enhanced when there is continuity of care—of midwifery led care in particular. In Australia, over decades, we have seen that birthing of babies has become almost completely medicalised. Babies are born in hospital with the support and oversight of an obstetrician, a doctor. This hasn't happened in all countries. I am sure lots of us have seen the wonderful TV series Call the Midwife, which really illustrates beautifully how midwifery led care is a hallmark of British society, and there are lots of other countries that have similar systems set up, where midwives lead the care from the minute the mother notifies the service that they are pregnant right through to the birth.

Right now in Australia we see that this has changed. We don't really have a service like that anymore. There have been midwifery led care models set up very successfully around the country—and, again, we heard about very successful ones from the member for Indi. There are great models of care where midwives work in collaboration with GPs and obstetricians. I'm pleased to say that many public hospitals, particularly in my area in Melbourne, are now initiating the midwifery models of care that are run in conjunction with medical experts, but it is the midwives who actually do all of the initial assessments and ongoing care, and call in medical experts when they are needed.

When we live in a land where choice is valued so dearly in all aspects of life, it is amazing that, at the beginning of a life, when a mother is giving birth, her choices are severely limited and she is denied choice—because, as I said, this bill does not cover midwives who wish to help mums deliver in their own home. Homebirths are not covered, and I think this is unfortunate. We know that at the moment there are 150 private midwives doing homebirths in this country, but they are doing it without insurance. This is far from optimal for both the mum and the midwife if something were to go wrong. It makes it very difficult.

I do understand that there are benefits with this bill. I have been told by the ANMF and my colleagues at the College of Midwives that it is good for nurses practising in those private practices and also for nurses working in Aboriginal communities, where we know child mortality is a very important issue and something that we need to work on. Of course, as previous speakers have pointed out, we know that midwifery led care does have enhanced outcomes, and, in those Aboriginal communities in particular, I understand that we are getting really excellent outcomes.

So, whilst we do support this bill and we know it does enhance the very important work of midwives in our community, we are still concerned that it falls short in helping midwives to establish private practice and, in particular, to do homebirths. I think that is something this country is lacking when I see how successful such models are in other countries. We will support this bill but we do hope that these other issues are going to be addressed by this government.

10:59 am

Photo of Stuart RobertStuart Robert (Fadden, Liberal Party, Minister for the National Disability Insurance Scheme) Share this | | Hansard source

I thank all members for their contributions to the debate on the Medical and Midwife Indemnity Legislation Amendment Bill 2019. This bill amends the Medical Indemnity Act 2002 and related legislation to reduce and simplify the legislation underpinning the medical indemnity schemes through consolidation and repeal of redundant legislation. The new legislation will continue to ensure medical indemnity insurance products are both available to and affordable for medical and allied health practitioners. Improvements have been made to the provision of universal cover for doctors who may otherwise be uninsurable. While there is a risk that poor performing doctors benefit from universal cover, the reason it exists is to protect doctors with a significant claims history from being denied cover where the claims history relates to their specialty, location or patient cohort. The risk is mitigated by increasing the risk loading which insurers can apply, and by enabling insurers to refuse cover in exceptional circumstances.

Only four of the six participating insurers have a contract with the Commonwealth. The effect of this has been that the two insurers outside of these contractual arrangements cannot be compelled to provide cover, and there is no mechanism to enforce universal cover. The effect of the contractual arrangements has therefore been unevenly distributed. Insurers will continue to be able to impose risk-management conditions on high-risk doctors and to refuse insurance in exceptional circumstances. These new arrangements will reduce administrative requirements and insurers will no longer need to contract with the Commonwealth, removing inequities between contracted and non-contracted parties. This will reduce burdensome and duplicate reporting and ensure there is an equitable and open medical indemnity insurance market.

The government will also be maintaining support for high-cost claims and exceptional claims made in respect of health practitioners who are insured by insurers presently participating in the schemes. These practitioners will need to be practising in professions accredited by the Australian Health Practitioner Regulation Authority. For allied health professions, included employed, privately practising midwives, the government will be establishing separate schemes for high-cost claims and exceptional claims. The allied health schemes will mirror the existing high-cost claims and exceptional claims schemes to include midwives and close an inequitable gap. This means that all registered midwives not covered under the midwife professional indemnity Commonwealth contribution scheme are covered under the allied health high-cost claims scheme. Claims made under these schemes will apply regardless of whether they are made against a practitioner covered by an insurance contract between the individual practitioner and insurer or by an insurance contract between the practitioner's employer and insurer. However, the claim must be against the individual practitioner. The amendments in the bill will ensure parity arrangements for doctors, allied health practitioners and midwives.

In summary, these legislative changes support the recommendations of both the first principles and thematic reviews, while addressing recommendations made by the Australian National Audit Office. The government will continue to ensure improvements are made in the monitoring of the performance of the Indemnity Insurance Fund against its objectives through the delivery of the independent actuarial evaluation, to be tabled in parliament in 2021. I commend the bill to the House.

Photo of Tony SmithTony Smith (Speaker) Share this | | Hansard source

The original question was that this bill be now read a second time. To this the honourable member for McMahon has moved as an amendment that all words after 'That' be omitted with a view to substituting other words. The immediate question before the House is that the amendment moved by the member for McMahon be agreed to.