Senate debates

Monday, 15 March 2010

Health Legislation Amendment (Midwives and Nurse Practitioners) Bill 2009; Midwife Professional Indemnity (Commonwealth Contribution) Scheme Bill 2009; Midwife Professional Indemnity (Run-Off Cover Support Payment) Bill 2009

Second Reading

Debate resumed from 9 September 2009, on motion by Senator Ludwig:

That these bills be now read a second time.

7:33 pm

Photo of Stephen ParryStephen Parry (Tasmania, Liberal Party) Share this | | Hansard source

I rise to be the first coalition speaker on the Health Legislation Amendment (Midwives and Nurse Practitioners) Bill 2009 and the related bills. The way I have to rise to do this is disappointing because I need to correct the record for Ms Roxon, the Minister for Health and Ageing, who has been scathing about the process in the Senate in relation to these bills. I quote Ms Roxon. She said—

Photo of Stephen ConroyStephen Conroy (Victoria, Australian Labor Party, Deputy Leader of the Government in the Senate) Share this | | Hansard source

You are a disgrace!

Photo of Stephen ParryStephen Parry (Tasmania, Liberal Party) Share this | | Hansard source

Senator Conroy interjects about us being a disgrace. I was going to let him off the hook; I was not going to embarrass him; but now that he has injected I will say that we just had a quorum called because the government could only muster one senator to attend the chamber. We had four or five on our side and you had one on your side after a dinner suspension. That is pretty ordinary, I think. I was baited by the minister and I mention that now. The minister needs to get his program a bit more organised. It is typical of the government’s program—and this is where we have been heading for some time.

Minister Roxon has blamed the opposition in the Senate for the delay in this legislation proceeding. That is an absolute load of rubbish. Let me give you the chronology since this legislation started. The one accurate thing that the minister said in her statement was that the bill passed through the House of Representatives on 8 September last year. The minister was correct—that is absolutely spot-on: the legislation did pass through the House of Representatives on 8 September last year, and here we are considering it today.

We are considering it today for a variety of reasons. Everyone understands—even speakers on the government side have said for some time—that the government determines the order in which bills are presented to the Senate. Everyone knows that, if you want a bill to be presented to this Senate and debated in the chamber, you list it at a position where it can be considered. There must be some reason the Senate has not yet considered these bills. The Leader of the Government in the Senate, the minister or, indeed, any of the ministers on that side could have delayed the introduction of this bill. If you introduce a bill on a Monday or a Tuesday and it is high up in the order of business, that is fine—it will be debated. When you introduce a bill on a Wednesday you have very little time—

Photo of Stephen ConroyStephen Conroy (Victoria, Australian Labor Party, Deputy Leader of the Government in the Senate) Share this | | Hansard source

Give us more time, you hypocrite!

Photo of Stephen ParryStephen Parry (Tasmania, Liberal Party) Share this | | Hansard source

Senator Conroy calls for more time.

Photo of Stephen ConroyStephen Conroy (Victoria, Australian Labor Party, Deputy Leader of the Government in the Senate) Share this | | Hansard source

Senator Conroy interjecting

Photo of Mark BishopMark Bishop (WA, Australian Labor Party) Share this | | Hansard source


Photo of Stephen ParryStephen Parry (Tasmania, Liberal Party) Share this | | Hansard source

I will take him back to July, August and October last year, when I and senators on the crossbenches said, ‘When you plan your program for 2010, put enough sitting weeks in that program. Don’t make it the shortest program of sitting weeks you’ve ever had.’ This is what the government has done for two years in a row. You cannot then come in at the last minute and say, ‘We need additional sitting hours,’ when you had the chance back in October. What have they done? The Prime Minister, who knows very little about the Senate and is starting to wake up that the Senate is quite an important place, has planned the entire sitting schedule against his overseas travel itinerary. We need more sitting weeks—that is correct, Senator Conroy—but you should have planned it in October last year; you cannot just do it on the day before you want extra sitting hours.

Photo of Stephen ConroyStephen Conroy (Victoria, Australian Labor Party, Deputy Leader of the Government in the Senate) Share this | | Hansard source

You are no longer the government. I know you’re struggling to come to terms with that.

Photo of Stephen ParryStephen Parry (Tasmania, Liberal Party) Share this | | Hansard source

Senator Conroy says we are no longer the government—it is very sad for Australia, but that is correct. I just hope that the people of Australia see the mismanagement by the other side, evidenced on a daily basis.

Let us go back to the chronology. The minister or the Leader of the Government in the Senate or whoever is responsible for this mismanagement introduced the bills in the week commencing on 14 September 2009, but the bills were listed last on a Wednesday, not first on Monday or first on Tuesday, in the knowledge that they would never see the light of day that week. We never heard of them again. On 26 October 2009, the bills were listed again not on Monday or Tuesday but last on a  Wednesday. In the week of 16 November, there was an opportunity to list them; however, they made neither the last Wednesday nor even the week. They were not listed for that week. On 23 November, they were not listed either. I make some allowance for the government on this, because they went to a committee. We allowed that to take place and came back in the new year, but in the week of 2 February—that is, after the committee had well and truly reported—the bills, lo and behold, were not listed again! So the urgency of these bills has somehow been diminished on many occasions.

In the week of 22 February, they were listed on Tuesday, but they were listed for that day after the fairer private health bills. Everyone from the most junior person in this place to the cabinet knew that the fairer health measures were going to be debated heavily and strenuously, so listing the bills presently under consideration just after the fairer private health insurance incentives bills might have just been a copout to again not to get to the bills.

In the week of 9 March, what happened? They were not listed. Now they have been listed. This is government incompetence. For some reason, someone forgets about them and they are not listed, so what does the minister do? The minister says, ‘My gosh, we’ve made a huge mistake here; let’s blame the opposition in the Senate.’ You are going to keep doing this until the next election. This is total mismanagement on the government’s part. The government has to understand that the Senate needs to run in a proper and fair manner. The way the Senate should run is, first, that there be adequate sitting weeks planned well before the year commences and, secondly, that ministers understand how the process works and not go to the media thinking: ‘We’ll just do a cover off on this. We’ll just blame the opposition in the Senate.’ The government has been totally caught out again. I put the minister on notice: do not try this cheap political stunt again because we will hammer you every time you misrepresent the truth.

7:39 pm

Photo of Rachel SiewertRachel Siewert (WA, Australian Greens) Share this | | Hansard source

The Australian Greens broadly welcome the initiatives contained in 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. These initiatives have the intention of enabling nursing practitioners and some, though not all, appropriately qualified midwives to request appropriate diagnostic imaging and pathology under Medicare, prescribe certain medicines under the Pharmaceutical Benefits Scheme and make referrals under the Medicare Benefits Scheme. However, there are two aspects of these bills that we find unsatisfactory: the right of a woman to have the choice to give birth outside the hospital system is not appropriately or adequately dealt with and the provisions in the bills regarding collaborative arrangements between midwives or nursing practitioners and doctors.

A lot of the debate around these bills has centred on home births and quite rightly so. I am not diminishing the other important issues that are dealt with in these bills, and I will come to those, but this is an area that has attracted a lot of attention. As noted by many submissions and witnesses to the initial Senate Community Affairs Legislation Committee inquiry last August—we have had two inquiries into various provisions of these bills—the scheme outlined in these bills does not address the needs of many Australian women who wish to have the choice of a home birth. Initially, the effect of the concurrent introduction of these bills and the national registration for health practitioners scheme, referred to commonly as ‘bill b’ as part of the NRAS scheme, was that independent midwives would not be able to practise with registration as there was no available insurance product on the market to provide them with indemnity cover. There has been no professional indemnity insurance for independent midwives in Australia since 2001. Midwives in private practice have not been able to obtain insurance and have been practising uninsured. We are pleased that the government has recognised this for certain categories of midwife—I think that is extremely important, and I should have said that at the outset—but the effect of the legislation when it was initially introduced was to make it essentially illegal for independent midwives to provide midwifery services for home births.

On 4 September, the Australian health ministers met in Canberra and announced a transition clause in the draft national registration and accreditation scheme legislation. This provided a two-year exemption until June 2012 for privately practising midwives requiring indemnity insurance. As part of a package of measures, private practising midwives were required to participate in a quality and safety framework being developed in consultation by Victoria through the finalisation of the registration and accreditation process. The process of this legislation, which has sought to bring about significant changes to midwifery practice in Australia, has been undertaken in a fragmented and uncoordinated manner. We are very concerned about the fact that the government seems not to have foreseen some of the issues here, has made a series of amendments and that there has been a series of ongoing negotiations around the safety and quality framework which seem to be separate from some of the other collaborative arrangements and some of the other negotiations that have been undertaken.

The lack of initial consultation with the key stakeholders and the failure to identify the overlap and contradictions between these two major legislative measures at the outset of this process made it unnecessarily complicated and chaotic. To pick up some of the comments that Senator Parry made, if some of these issues had been dealt with by the government in the first place we would not have seen this legislation delayed as long as it has been. The Greens shared the concern raised by a number of witnesses to the Community Affairs Legislation Committee inquiry that, under the provisions of these bills, if registered midwives were unable to attend a home birth there was a very real potential that many women would still choose to give birth at home. The government saying that there should not be home births does not mean that Australian women will not make that choice. In fact, I had a number of mothers and expectant mothers say to me: ‘We want a home birth. The fact that the government thinks that it can make it virtually illegal does not mean that we are not going to choose to have a home birth.’ Unfortunately, they would have had to have made the choice of it being unsupported or done with the help of non-registered midwives.

When this issue was raised, some people in the government did not seem to think that it was a problem that people would be using non-registered midwives. It seems to me that it was a complete contradiction that the government wanted to set up a national registration scheme and certain people from government were saying, ‘What’s the problem with non-registered midwives? As long as they don’t call themselves midwives, it’s not a problem.’ This would increase the risk of negative outcomes for mothers and newborns. The government mitigated the immediacy of this problem when the announcement was made about the two-year exemption, but it is yet to indicate how it intends to solve the problem of access to midwifery care for homebirth in the long run. It seems to have delayed the successful outcome of negotiations and a resolution of the problem, as it sees it in terms of dealing with homebirths, to just two years down the track.

The government has done nothing to allay the fears of those who believe the future of homebirthing and the ability of women to choose the location of their birthing is being undermined by the ideology of some sections of this country’s medical profession. The Greens believe that the choice of having a low-risk homebirth should be available in Australia. The government needs to recognise that there are a significant number of women who want to birth at home. I do not know when the government is going to take this message on board and realise that women want the choice. They want to be able to birth at home. There are a number of women who want to be able to birth at home. There are a number of women who have birthed at home and want to have their next birth at home. There are a number of women who may not even want a birth at home but they absolutely support the right of women to have the choice of birthing at home.

The Greens support the requirement that practitioners hold adequate indemnity insurance. The exemption of private practice midwives providing homebirth care from this requirement should only be considered as a temporary measure until access to professional indemnity insurance has been resolved. We are very concerned about this legislation. As I said, we are pleased that an indemnity insurance scheme is being introduced. It is long overdue. What we have concerns about is the fact that midwives providing homebirths have been excluded. The insurance scheme should not be dependent on the location where a woman and her family choose to birth. Research indicates that well-integrated models of homebirth care are safe. However, homebirth, predominantly in the private sector, has been marginalised by some medical profession bodies and lobby groups. This marginalisation has made it extremely difficult for individual private midwives to integrate their care into hospital based maternity services.

I have lost count of the number of women and midwives I have spoken to who have had very significant difficulties in talking to hospitals to integrate their care. Midwives are very keen to integrate their care into the hospital system, but in many, many cases they have been denied that access. It is important at this juncture of the reform process that consideration is given to ways of better integrating private homebirth care into the delivery of maternity services rather than taking an approach that could potentially drive homebirth underground. The Greens consider that the model of homebirth proposed by the Australian College of Midwives has particular merit. This model ensures that quality practitioners who are experienced, credentialed and completing continuing professional development will use collaborative processes for consultation and referral according to nationally agreed guidelines to provide care for low-risk women. Under this proposal, indemnity insurance would only be extended to midwives who are Medicare eligible. These midwives will have already undertaken a credentialing process, will be linked to models of professional development and will work in collaboration with medical practitioners.

Evidence based guidelines should be used by midwives in making decisions regarding consultation and referral of the care of women. There is a need for nationally endorsed guidelines to support midwifery care. These guidelines should be for all areas of maternity care, including antenatal care, minimum standards of care in labour, caesarean section birth care, after caesarean section care and care for women with twins and breech birth babies. Such guidelines exist in other developed countries and inform practice. The maternity review recommended the development of guidelines, and this should be progressed as a priority. The adoption of a policy or a framework for private practice midwives providing homebirth care could be a way to progress the issue of indemnity while addressing insurance risk concerns.

One of the issues that have been a central part of this discussion is collaborative arrangements. This issue has been debated at length and it is one of the other areas that delayed the legislation. When the government realised that there were still some issues with the legislation, they introduced another amendment requiring collaborative arrangements. That had to be reviewed because we felt that there were significant changes. We had deep concerns. Also, countless women made representations, certainly to the Greens. I am sure all the other politicians in this place also got representations from mothers and midwives raising concerns about the government’s amendment that was introduced late last year.

On 28 October last year the government circulated amendments to the Health Legislation Amendment (Midwives and Nurse Practitioners) Bill 2009 and the Midwife Professional Indemnity (Commonwealth Contribution) Scheme Bill 2009. These amendments were designed to clarify in legislation that eligible midwives and nurse practitioners wishing to access the new arrangements would be required to have collaborative arrangements with medical practitioners. The details of the arrangements were to be specified in secondary legislation. The Greens were alarmed at the implications of these changes. A midwife or nurse practitioner would not be able to their job without the threat of veto from a doctor. In other words, it put a doctor in the position of having power of veto. If unamended, the only midwives who would be able to participate in the new arrangements would be those working directly in the rooms of obstetricians. This would be a long way from fulfilling the vision articulated by the minister of enhancing women’s access to care from midwives across all communities in Australia. For midwives who want to work in obstetricians’ rooms, that would not be a problem, but it would be a problem for a large number of other midwives.


The Greens referred the amendments to a second Community Affairs Legislation Committee inquiry to specifically look at the implications of the amendments. On 8 December, the Minister for Health and Ageing, Ms Roxon, wrote to the committee’s chair indicating that the circulated amendments were intended to clarify in legislation the collaborative intent that had been articulated. The minister went on to advise that after further consideration of the issues raised by stakeholders in relation to access to professional indemnity insurance—in other words, there were problems with the amendments, so this is the second lot of amendments that the government has to make to its legislation or to the process—and subsequent registration under the NRAS, she was persuaded that it was not necessarily desirable to just proceed with the collaborative arrangements in one of the bills, which was the Midwife Professional Indemnity (Commonwealth Contribution) Scheme Bill 2009.

In the second community affairs committee inquiry into the bills, Dr Barbara Vernon, the Executive Officer of the Australian College of Midwives indicated to the committee that all stakeholders had largely agreed on the issues around eligibility. She said:

The key issue around eligibility that is problematic is whether or not we add this additional requirement of an arrangement with a doctor as to whether or not the midwife is going to be a capable, safe and competent practitioner in providing this care, and that is where there is a difference of opinion. But the material on midwives and their qualifications et cetera has been largely agreed upon, and it is likely that the Nursing and Midwifery Board of Australia would have carriage of administering that; they would have some kind of mechanism for identifying these midwives and maintaining their eligibility over time.

The department also commented on the progress to establish what was meant by eligible midwives and informed the committee that a very broad consensus had been reached around the level of experience that would be expected of an eligible midwife and that the midwife would need to have practised in a number of settings. We are yet to be informed of the outcome of these discussions that the department started.

The Greens acknowledge and support the minister’s intention that Medicare funded midwives should work collaboratively with medical and other health professionals as needed in the care of women and their babies. That issue is absolutely not in dispute. We completely agree. We do not, however, agree that it is necessary to legislate for collaborative arrangements in order to achieve this goal. Collaboration with medical and other health professionals is already encoded in the regulatory framework within which midwives work in Australia. Disciplinary action may be taken by regulatory boards if midwives are found to practise in a non-collaborative manner.

The Greens agree with the Australian College of Midwives that midwifery is a profession committed to the provision of collaborative care. We believe it is essential. Women choosing the care of a private MBS funded midwife must have ready access to appropriate medical care if and when the need arises for themselves or their baby. The issue is how collaboration is ensured. The Greens believe the inclusion of collaborative arrangements in the manner in which it is proposed in this legislation may undermine how midwives work collaboratively with the medical and other health professionals. The Australian College of Midwives says that midwives should be able to demonstrate their adherence to safe, collaborative practice through the use of formalised maternity care notes for each woman for whom they provide care, which can be audited by Medicare Australia or the Nursing and Midwifery Board of Australia as appropriate. This seems to us to be a very sensible way forward.

The Greens agree with the Australian Nursing Federation that the consequence of the government’s amendments to the bills will mean that a medical practitioner could have veto over the ability of a midwife to practise. The Greens agree with the Australian Nursing and Midwifery Council, who have argued that collaborative practice between midwives and nurse practitioners and other health professionals is already legislated through the professional framework developed by the Australian Nursing and Midwifery Council. We remain concerned that the legislation should be presented to parliament before advisory groups have been able to complete their work—the very groups that the minister has set in place—and believe that this has contributed to the confusion and concern felt by many, not least by the public themselves.

The Greens support the minister’s intention that Medicare funded midwives should work collaboratively with medical and other health professionals as needed, as I have said. We do not agree that these legislative practices are necessary. We believe having collaboration in the legislation is not necessary. Collaboration with medical and other health professionals is already encoded, as I said, and there is provision for disciplinary action. In order for midwives to do their job, it is absolutely essential that they are involved in collaborative care. I have certainly had extensive consultation that I have undertaken with midwives and with mothers—and I have been ignoring fathers—and with fathers. When you go to a rally on homebirth, the fathers are always there as well. They are totally supportive and they want homebirth as well. We should not—and I should not—keep referring just to mothers. Fathers and families want the provision of homebirth. They support the indemnity insurance scheme and they want it extended to homebirths. They have very strong concerns about collaborative arrangements.

As I said, it is the midwives who are always talking about collaborative arrangements. It is the midwives who raise concerns with me about the fact that they have not been able to get collaborative arrangements with doctors. That is particularly important in regional centres. I note the number of emails, telephone messages and conversations I have had from women and men in Australia, particularly from regional centres, who have said that they have not been able to get a homebirth in their centre because their midwife has not been able to access collaborative arrangements.

As a Green, I do not want any mistake made; we do support collaborative arrangements and provisions. We do not support the way the amendments that have been proposed for this legislation enable a doctor to have a power of veto. That puts limits over a midwife being able to practise. That in itself starts to suggests to me that that is no longer a collaborative arrangement. That is a power imbalance between a midwife and a doctor. It is likely, unfortunately, that in many cases doctors will exercise that power of veto. That is why the Greens are proposing some amendments to provide for collaborative practice but not mandate collaborative arrangements as is articulated in this legislation.

The government made some mistakes in this legislation. We support the intent of the legislation but not some of the provisions. The government got it wrong twice. That is what held up this legislation. I do not always agree with Senator Parry but I agree with him on this one. It is disingenuous for the government to blame the Senate for this legislation being held up. In fact, we have helped you make it better, Guys. We have identified the problems with this legislation and we have been communicating with the public. If it was not for the pressure from the various people in this place and the public, you would still be going ahead with that flawed NRAS legislation which effectively outlawed homebirths. So stop having a go at the Senate about this particular legislation and look at the changes that were made.

Photo of Mark BishopMark Bishop (WA, Australian Labor Party) Share this | | Hansard source

Senator Siewert, your time has expired. Before you resume your seat, do you want to move your amendment to the second reading motion?

Photo of Rachel SiewertRachel Siewert (WA, Australian Greens) Share this | | Hansard source

Yes, I move:

At the end of the motion, add: 

                 and the Senate calls on the Government:

             (a)    to ensure that midwives have access to a contract of insurance that provides midwife professional indemnity cover for a person irrespective of the location or venue of the births that they attend; and

             (b)    to undertake a thorough review, 12 months after the regulations under this legislation commence, to ensure that the collaborative arrangements as stipulated in the regulations are effective and have in no way obstructed independent midwifery practice.

8:00 pm

Photo of Concetta Fierravanti-WellsConcetta Fierravanti-Wells (NSW, Liberal Party, Shadow Minister for Ageing) Share this | | Hansard source

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

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

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

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

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

is licensed, registered or authorised to practice midwifery by or under a law of the Commonwealth, a State or a Territory; and
meets such other requirements (if any) as are specified in the Rules for the purposes of this paragraph; and
is not included in a class of persons specified in the Rules for the purposes of this paragraph.

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

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

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

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

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

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


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

8:18 pm

Photo of Glenn SterleGlenn Sterle (WA, Australian Labor Party) Share this | | Hansard source

I rise to comment on the Health Legislation Amendment (Midwives and Nurse Practitioners) Bill 2009, theMidwife Professional Indemnity (Commonwealth Contribution) Scheme Bill 2009 and the Midwife Professional Indemnity (Run-off Cover Support Payment) Bill 2009. These are particularly important and timely health bills and are a great credit to the Minister for Health and Ageing, the member for Gellibrand. I think this country is very fortunate to have such an outstanding minister. The measures contained in these bills are an essential step forward in the necessary reform of Australia’s health system. They will make lasting changes, for the better, in the way health services are delivered in this country. My only regret is that they could have come much sooner had it not been for the lack of effective action by the previous coalition government.

It is gross hypocrisy for opposition senators, including Senator Fierravanti-Wells, to come into this chamber and try to make out that they are the champions for the cause of private midwives and nurse practitioners when, for at least a decade, the coalition repeatedly failed to support, in any real and practical way, the very valuable roles carried out by nurse practitioners and private midwives. It has all gone quiet on the opposition side, Mr Acting Deputy President!

Measures contained in these bills will enable the implementation of the $120 million 2009-2010 budget commitment to improve choice of and access to maternity services. The maternity services reform package, made possible by this budget allocation, is the outcome of a very wide-ranging review of Australia’s maternity services. The 2009 Maternity Services Review, which was led by Rosemary Bryant, the Commonwealth Chief Nurse and Midwifery Officer, received over 900 submissions from a broad cross-section of stakeholders. Many of these submissions drew upon the personal experiences of women accessing available maternity services.

These bills will significantly improve maternity care options for women while ensuring that there is a strong framework of quality and safety for mothers and babies. The improved maternity service arrangements made possible by these bills should enable many more women to have access to maternity care closer to home.

Women who made submissions to the maternity services review were almost universally dissatisfied with the maternity care options available to them. In particular, they gave high priority to having access to midwifery models of care that were capable of and committed to providing continuity of maternity care from antenatal care, to birthing, through to postnatal care. The review found that too often the current system of maternity care was uncoordinated and, unfortunately, disjointed. The enhancement of the role of midwives that these bills will facilitate will ensure many more women will have the benefit of a coordinated care pathway from pregnancy through to professional postnatal care.

The measures contained in these bills are very much about promoting and enhancing multidisciplinary and professional collaboration in the provision of maternity care in Australia. The importance of collaborative multidisciplinary maternity care in order to ensure the delivery of high quality, safe and supported maternity care was confirmed by the various health professional groups.

This package of bills will enable eligible midwives to have access to the Medical Benefits Scheme and to the Pharmaceutical Benefits Scheme under appropriate arrangements. These arrangements include a requirement to work in collaborative arrangements with obstetricians and GP obstetricians. This requirement is an important practical aspect of a best practice multidisciplinary model of maternity care. It will foster and enhance the professional relationships that are essential in providing safe and high quality maternity care.

The minister has advised that at this stage it is not proposed to include home births in the new arrangements for midwives. The reason is that the maternity services review did not recommend that public funding should be provided for home birthing. Hence the government’s proposed professional indemnity insurance arrangements for private midwives do not include cover for attending home births. However, it also needs to be said that these bills do not take away any current rights in respect to home birthing.

It has been recognised, nonetheless, that there has been concern that the proposed national registration and accreditation for health professionals could make it unlawful for private midwives to practice without appropriate professional indemnity insurance. In this regard, the minister has advised that the planned national registration and accreditation legislation for health workers will include a transitional clause that will provide a two-year exemption, until 2012, from the requirement for privately practicing midwives who are unable to obtain professional indemnity insurance for attending a home birth to hold professional indemnity insurance. In order to access this exemption it will be a requirement for midwives attending homebirths to provide full disclosure to their clients that the midwife does not have professional indemnity insurance and to receive informed consent.

As well, midwives will be required to report each homebirth and to participate in safety frameworks which will be developed after consultation—led by consultation in Victoria. This measure will provide an added safeguard in ensuring the maintenance of high standards of quality and safety with regard to homebirths attended by nationally accredited midwives. In other words, the current arrangements will continue in respect to homebirths. If a mother has chosen to have a child at home and has been properly informed that the activity will not be insured, as is currently the case, the midwife will not be at risk of deregistration or penalty. It is important to note that this is no different to the situation that pertained during the period of the Howard government, except that there will be added quality and safety measures in respect to midwife attended home births.

I would now like to move on to discuss nurse practitioner reform measures that are contained in the proposed legislation. These measures will greatly enhance the role of nurse practitioners and their effectiveness in supporting essential primary care and other specialist nurse practitioner roles in the community. I believe that an enhanced role for nurse practitioners has the potential to greatly improve access to primary care services and to add significantly to the efficiency and effectiveness of primary care and chronic disease care in Australia.

The bottom line is that, unless we move to fully utilise the expertise and skills of our existing health workforce, Australia will face extreme difficulty in adequately meeting the health service needs of Australia’s growing and ageing population. It is important to note that nurse practitioners are by no means a new invention. They have been essential members of the health workforce of many OECD countries for many years. In fact, in some countries nurse practitioners have been in existence for over 40 years. Why then has Australia lagged so far behind the rest of the developed world with regard to nurse practitioners? The answer is simple: the medical profession, backed by the Liberal Party and the National Party, has persistently stymied an increased healthcare role for qualified nurse practitioners. The AMA is the greatest workplace turf protection outfit in this country, bar none. The turf war continues to this day even if it has become a little less overt.

For example, in respect to nurse practitioners, the AMA has not come up with a shred of credible evidence that the use of nurse practitioners in primary care lowers either access to or provision of high quality primary care. Too many doctors, egged on by the AMA’s closed shop specialists, remain antagonistic and suspicious of the concept of nurse practitioners. In this regard it is discouraging to find on the Australian Medical Association website an AMA position paper in respect to nurse practitioners which states:

The role of a nurse in the primary care setting does not include:

  • Formulating medical diagnosis
  • Referring patients to specialists
  • Independent ordering of pathology or radiology
  • Prescribing medication and issuing repeat prescriptions.

In other words, the official position of the AMA, as stated on its website, is to firmly ring fence anything that it regards as doctor territory regardless of benefit to patients or the health system. The AMA’s position statement with respect to nurse practitioners illustrates an even more important issue: namely, the poor record of the medical profession and its union—and they are a union, and a very powerful union; they do not like being called a union, but they are a union—to embrace the need for reform of the broader healthcare delivery model. The fact is that the inflexibility of politically powerful elements within the medical profession is harming the attainment of sustainable, efficient and high quality healthcare delivery for all Australians.

Maintaining entrenched regressive positions about the retention of turf rather than having regard to best practice healthcare delivery will in the end serve neither the interests of patients nor the interests of health providers. It is of meagre benefit to patients to be told that the quality of medical and health care provided in Australia stands alongside the best in the world if, when they need to access a healthcare service, they encounter significant and unnecessary obstacles to gaining access to needed health care. It has been recognised for well over a decade that Australia faces major challenges in maintaining and expanding its health workforce into the future. Australia’s health workforce is currently growing at approximately twice the rate of its total workforce growth. Already health workforce shortages are creating significant difficulties in meeting the medical and health service needs of a growing and ageing population. This is particularly so for people living in rural and remote areas and in the outer urban areas of Australia’s major cities. On current trends, the ability of Australia to maintain the current rate of health workforce growth seems, sadly, unlikely to be sustainable.

Hence it is necessary to ensure that Australia achieves maximum output and productivity from its existing health workforce. This will inevitably require changes to the structure of the health workforce and, where appropriate, to the roles of individual health workforce categories. The time has come when we cannot afford to have necessary health workforce reform stifled or stalled by vested interests of the various health occupations and health professional groups, particularly the Australian Medical Association. The fact is that many of the required reforms, such as an enhanced role for midwives and nurse practitioners, in reality are neither radical nor all that difficult to implement.

Australia has a nurse workforce of over 200,000 well-trained and well-educated nurses dedicated to professional excellence. Added to this, many nurses, through scholarship and personal initiative, have accumulated extensive experience in complex areas of healthcare delivery and hold postgraduate qualifications in their chosen health discipline and medical specialty. Certainly anyone who has had cause to attend a busy public hospital or who has witnessed the workload of a remote area nurse in, say, the north-west of Western Australia knows from direct personal observation the capabilities of nurses to deal with complex clinical situations. We need to ensure that our nurse workforce is able to continue to develop its skills and capacity to meet the complex healthcare service needs of Australia’s growing and ageing population. Access to required high-quality healthcare services is already a significant issue for Australia—for many people living in rural Australia, for people with mental illness and for many frail aged people. This situation will only get worse if we do not make better use of the skills and capabilities of our existing health workforce.

Members of the Howard government cannot claim to have been unaware of this problem. Senior health officials and planners have been drawing attention to Australia’s looming health workforce crisis for years. In 2005, at the request of the Howard government, the Productivity Commission undertook an extensive investigation into Australia’s health workforce issues. The Productivity Commission was requested:

... to undertake a research study to examine the issues impacting on the health workforce, including the supply of, and demand for, health workforce professionals, and proposed solutions to ensure the continued delivery of quality health care over the next 10 years.

The request to the Productivity Commission went on to say:

The study is to be undertaken in the context of the need for efficient and effective delivery of health services in an environment of demographic change, technological advances and rising health costs.

The Productivity Commission submitted its report to the government in December 2005. In its study the commission found:

... measures aimed at boosting the supply of health workers will not by themselves be sufficient to provide a sustainable solution to Australia’s health delivery needs. In particular, they will not address inefficient and inflexible workplace arrangements that reduce the productivity of the available workforce.

Even cursory reading of the commission’s report would leave most readers in little doubt that the latter comment concerning inefficient and inflexible workplace arrangements is largely directed at the tactics of the strongest occupational group in the country: the doctors and the doctors’ union—in other words, the AMA. It is an undeniable fact that, whereas most other occupations have had to adjust and accept wide-ranging workplace change in the cause of economic reform, the medical profession has been almost totally untouched by these events. The medical profession has been cocooned from workplace reform, and this is costing the taxpayer dearly as total healthcare costs continue to rise faster than the value of Australia’s GDP. This is unsustainable in the long term.

Finally, the measures in the proposed legislation of enabling eligible nurse practitioners to access the MBS and the PBS, to prescribe certain medicines and to have rights to refer to specialists is exactly the sort of critical action required to increase the efficiency and effectiveness of the available health workforce. These measures will significantly improve access to primary care services where there are shortages of medical practitioners and where timely access is too often problematic. The Minister for Health and Ageing and her department are to be congratulated on bringing forward these healthcare delivery changes. Not only are the changes urgently needed but also I am sure that they will be a huge success and will benefit thousands of Australians throughout the country. I commend the bills to the Senate.

8:36 pm

Photo of Ian MacdonaldIan Macdonald (Queensland, Liberal Party, Shadow Parliamentary Secretary for Northern and Remote Australia) Share this | | Hansard source

I am indeed indebted to Senator Sterle for that very fine explanation of 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.

I do not come to this debate with any of that sort of expertise that Senator Sterle has shown. I wanted to speak tonight because, while I have to say it is not an area that I claim any expertise in at all, I was very impressed with the group of women in Townsville who came to see me and who explained this issue to me before I had really ever taken any interest in it. It probably does not need emphasising that I was someone who was not really terribly involved in this sort of policy issue. I said to them, ‘But wouldn’t you rather have your children in a hospital, where you have got immediate access to the very best of technical assistance, the very best of science, the very best medical expertise in the nurses and doctors and specialists all at hand?’ That seemed to me to be a common-sense provision. But after listening to these women—for about an hour, I think it was—I could understand their concerns at the legislation that the Labor government was bringing in. They had very real and genuine concerns. Apart from that, I have a concern about rural and regional Australia, and particularly northern remote Australia that I have some very great interest in. I just wonder where this legislation will leave people who are not very close to hospitals, to specialists and all that very best of attention. But I digress a little. I was very impressed with this group of women who came to see me in Townsville and the arguments they raised.

It has been the subject of great debate and in the end result the coalition has determined that the legislation is perhaps better than nothing. As colleagues have mentioned before, the coalition will not be opposing the passage of this bill. But I am concerned, and I readily understand the issues that this group of women who came to see me in Townsville have with this bill and with the general approach of the Labor Party to this issue. As I understand it, the government introduced legislation providing for MBS and PBS access for nurse practitioners and midwives to commence from 1 November 2010. The Commonwealth-subsidised indemnity insurance for midwives working in a collaborative setting is to commence on 1 July 2010. The legislation is in response to recommendations of the maternity services review. The indemnity insurance provisions will not, as I understand it, cover midwives providing birthing services outside of a clinical setting. I know that will be of great concern to many of my constituents who have spoken to me about this. The national registration and accreditation scheme will make indemnity insurance a mandatory requirement of registration as from 1 July this year. Therefore it will effectively be illegal for independent midwives to provide home birthing services from this date, and individuals who practise as midwives without registration face a maximum penalty of $30,000, in accordance with the exposure draft that came out in relation to the Health Practitioner Regulation National Law. Currently, as I understand it, insurers do not consider it viable to offer independent midwives indemnity insurance due to their small numbers and the lack of a risk profile. Women who have a home birth privately contracted with midwives without indemnity insurance, I can understand, have a great reason for concern.

Whilst we are in opposition and are powerless almost to get the right sort of legislation, this legislation, as I indicated, will not be opposed. But can I indicate that I am concerned for those who have a very genuine concern for having childbirth in the hospital systems and in what quite clearly the majority of Australians would consider is the right way to bring children into the world. But there are a very significant number of people who have very intense and well-grounded fears for the way that the state is, effectively, regulating what is their private lives.

I am also very concerned about the impact that this will have upon people living in remote and rural Australia. I often think that governments in Canberra and bureaucrats in Canberra do not really understand what life is like for admittedly a very small percentage of Australians. Indeed, they form a voting block which is of no significance whatsoever, but they are Australians and they deserve to be considered. I think it is very hard at times for ministers coming from capital cities to understand that there are places in Australia where you will drive eight hours to get to the closest hospital. You will wait for two days for the flying doctor service to come in and service your medical needs, including childbirth.

Legislation such as that we are dealing with today—and I think this is a very good example of this—really does not pay any attention to those Australians from remote and rural areas, who happily and stoically put up with their lot but who I think deserve some greater consideration. In the past they may have been able to give birth where they live, several hours from expert medical attention—when I say ‘expert’, sometimes they can get a midwife, and that is in my view expert medical attention; but in the common thinking they are remote from that—and they should have that option, they should have that choice. That is where I have some concerns with this bill.

I did not want to speak all that long on this. Earlier speakers from our side have indicated the coalition’s position, and have indicated very clearly the view that we take on this particular issue. Had we been in government we may have been taking a somewhat different approach. But I did want to speak in this debate to highlight the issues of those women who came to see me who very passionately believe in their right to give birth at home and to have the assistance, should they require it, of qualified midwives to help them with those births. I qualify my remarks by saying that this is not an area where I have any expertise—unlike Senator Sterle, who gave a very detailed and very keen explanation of the whole bill. Unusually for Senator Sterle, he read every single word of his speech; but, as I say, he clearly has a very keen and detailed interest in this. But I want to highlight the issues that have been made known to me and to indicate that, for the reasons my colleagues have pointed out, we will not be opposing the bill. I indicate in concluding that there are issues that I think do require further consideration by the government of the day.

8:48 pm

Photo of Judith AdamsJudith Adams (WA, Liberal Party) Share this | | Hansard source

I too rise this evening to speak on the Health Legislation Amendment (Midwives and Nurse Practitioners) Bill 2009 and related bills. Being the only trained nurse and midwife within this parliament, I feel that perhaps I do have a little expertise. Senator Moore, I and the other members of the Senate Community Affairs Legislation Committee also worked very hard with the people who came before us during two inquiries. The first inquiry was on 6 August 2009 and we had 1,958 submissions. Our second inquiry was on 17 December 2009 and we had 933 submissions. I think this indicates how very strongly the general public feel about this issue.

Might I say at the outset that I am very pleased that these bills have come forward, because 1 July was coming up very quickly. I feel very sorry for those women who will be having home births or have private midwives and will then be going, under the care of the private midwife, into a hospital to have their baby. This has been a terrible time for them. They have been put through an enormous amount of pressure. I can assure you, having had two children, that being pregnant is pretty hard—but, by gee, imagine that you are pregnant and you are not sure whether or not the person who has taken you through your pregnancy, who has been looking after you and supporting you, will be beside you after 1 July.

As I said, having sat through numerous deliveries in the time that I was working as a midwife, I can say it really is an exciting time. The fact is that as a midwife you tend to be with the patient, a complete stranger, in your hands, with her husband or her partner, and you go right through every contraction, through everything they are feeling—the angst, the anxiety. You are there to support them if things do not go right but also to congratulate them on having the birth of a normal, happy child. It is such a terrific area of nursing. Before I became a midwife I was working in operating theatres. You get to the stage—although this sounds very bad—where you have lists and lists of different types of operations that you are going to do; and, unfortunately, when your next-door neighbour comes down and goes through the theatre you do not realise who it is. I decided I had better go back to midwifery. I really do have a great passion for it.

I am not sure whether I heard Senator Sterle say that the coalition had not supported nurse practitioners, but I can assure you—going back probably 11 years in Western Australia, when we had the first nurse practitioners—just how supportive coalition and Liberal governments have been towards the nurse practitioner. Originally their role was to be to go to remote areas of Western Australia, and then later into remote areas in the rest of Australia. But, unfortunately, a number of the people who became qualified, having done their nursing, gained considerable experience and then gone on and done a masters degree—they are very well educated and well trained—decided they would rather work in the city, in the emergency departments and those areas. So I really would encourage anyone who is a nurse practitioner, if they could possibly go out and help in the rural areas, to do so. It would be a really great thing for rural areas.

We used to have what we called nursing post sisters. I did a lot of relieving in these areas as one. I think that a nurse practitioner could fill that role very adequately for the community. Unfortunately, as we are all aware, trying to attract GPs into rural areas is very difficult and trying to attract a GP who has qualifications in obstetrics is even harder because these people like to stay in the city and a number are not taking up the work because of the problems of litigation and the cost of their indemnity insurance.

We are looking at 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. For eligible nurse practitioners and midwives, the Health Legislation Amendment (Midwives and Nurse Practitioners) Bill will provide the right to request certain diagnostic imaging and pathology services for which a Medicare benefit may be paid; the right to prescribe certain medicines under the Pharmaceutical Benefits Scheme, known as the PBS; and new Medicare items and referrals under the Medicare Benefits Schedule, known as the MBS, for midwives and nurse practitioners working in collaborative arrangements with doctors.

I will speak later about the collaborative arrangements, which have been quite a problem, but I will say that the passage of these bills has been very difficult. At the supplementary budget estimates hearings in October it was very, very difficult to find out from the Department of Health and Ageing what the definitions of eligible midwife and nurse practitioner were. Unfortunately, the legislation had been put through but the regulations had not been prepared. Even some of the most experienced department officers could not answer the questions I asked. That made me very dubious about what was happening with these bills. It was one of the reasons that later, when we did get the completed legislation, we pushed very hard to have another hearing, as did members of the public. Senator Macdonald has spoken about the number of people that spoke to him about whether they could have a choice and have a home birth or go with their midwife and be able to go to a hospital if things did not quite work out.

As you can imagine, as the only midwife in the parliament, I have received a large number of emails and many people have come to see me. I felt privileged that those people chose to come and talk to me about their concerns. I was able to talk to them on a first-hand basis about their problems and how they were feeling. I do hope that the coalition will not be opposing these bills, so that on 1 July those mums-to-be and the midwives looking after them will be feeling a lot happier and more confident about their situation.

I have been very frustrated with all that has gone on since the legislation came out. I think that the members of the Senate Standing Committee on Community Affairs should be congratulated on the work they have done on this legislation. I am not satisfied with the end result, but I think it is a great start. Nurse practitioners will now have prescribing rights and be able to do a lot more than they are doing and our midwives are going to have the opportunity to continue practising rather than being fined if they continued to practise, as was the case with the first lot of legislation. That meant that probably 200 of the most experienced midwives in Australia were going to be penalised because the government had not looked at its national registration legislation, which conflicted completely with the fact that an eligible midwife had to have indemnity insurance. Unfortunately, those who work as homebirth midwives are ineligible to have insurance because no-one will insure them. That was a real worry and I would hate to have seen that happen, particularly as I know a number of these midwives. Also, it was not going to give women a choice.

As a midwife, I look at the safety of the mother and the baby. When the coalition senators submitted their additional comments to the inquiry we held in December we said we wanted some sort of arrangement where a woman who is having a baby has to be booked into a hospital and her midwife work with the local GP. Then if something were to go wrong the woman would be able to have a safe delivery in the hospital into which she had been booked. I believe that this is the safest way. Some of the women were saying they had had children before by homebirth with a midwife and everything had gone well, and they were having another one and saying, ‘If my midwife can’t do anything for me I am going to have a free birth.’ I would hate to see that. It is the last thing we want: a woman at home labouring, probably with children and her partner there. If something were to go wrong it would be a dreadful thing for a child to be present to see that happen.

Most midwives have an effective relationship with the doctor anyway. I just think back to my own days in the profession. The doctors knew what we were capable of. I was trained in New Zealand and we did most of the deliveries within the hospital and the GP came in later. They very rarely were there to do the delivery because they considered that the midwives were well practised in it and had been with the woman through her labour. The GPs did not want to interfere except to be there to congratulate the mother and her partner on the birth of their child.

Being a midwife, there are a lot of things I could say, and I will support these midwives so long as I am in this parliament. They play such a terrific role. During the inquiry there were issues raised by the AMA and the doctors, but I think there are terrific partnerships between health professionals. Evidence was given by the AMA, but, when members of national bodies give evidence at these inquiries, they tend to have moved away from or forgotten about their practical experience years ago—though I will not say that about the current president of the AMA, because he is an obstetrician and gynaecologist. It was hard because, obviously, the nurse practitioners and midwives are to be given rights that are normally restricted to the medical fraternity. But I think that as a team they can work together for the good of the community. With low-risk homebirths and the midwife’s collaboration with the doctor, hopefully it will all go very well.

This word ‘collaboration’ really has caused some problems. The doctors associations all wanted a signed agreement with midwives. In some rural hospitals only one doctor is on duty, but how many doctors perform obstetrics in the larger hospitals? Some babies come on time, but not many do and they come at all hours of the day and night and other people are on call. These collaborative arrangements meant that the midwife was going to have to have an arrangement with the medical superintendent or whoever was in charge of the other professionals who perform obstetrics, which would create a complication. The midwives were pushing for what they called a collaborative practice. Senator Siewert spoke about this. Collaborative practice is exactly what is happening now. All these hospitals have guidelines. The midwives are working under these guidelines and are fully aware of their rights and responsibilities, as are their patients. Unfortunately, this time around it was not to be. There will be a collaborative agreement, but I still feel that this legislation has moved mountains as far as nurse practitioners and midwives are concerned. I believe that it will bring together a much more cohesive team—and I do not want to omit the other allied health practitioners, who often are involved with the midwives in helping their patients.

It really is a step forward, but I do have a few reservations about the way that things went on. It did get a bit nasty, but as a committee we are quite used to that. We dealt with it very well and I am certainly proud to have been a member of the community affairs committee when it received this evidence and conducted the inquiries. The inquiries were very rushed, with only a day for each. With such a terrific number of submissions, we were able to accommodate a number of witnesses by having four or five community people there together giving evidence with the support of others rather than sitting alone at the witness table. We were able to achieve that, but, if the legislation had been a lot clearer, the regulations had been prepared and there had been a lot more consultation by the minister with the nurses, nurse practitioners, midwives and doctors, the Senate probably would have passed this suite of bills a lot sooner.

At least parents are going to be given a choice as to what happens. The midwives have guidelines. They know where they are going and what the consequences are. I hope that after these bills are passed, if certain issues have to be amended later, that will occur. I believe the committee did a great job. I congratulate the chair on the way in which she conducted these inquiries. As you can imagine, with the number of people who put submissions forward, there was a lot of disappointment because they could not all come before us. I will be supporting the legislation.

9:06 pm

Photo of Sue BoyceSue Boyce (Queensland, Liberal Party) Share this | | Hansard source

As has been pointed out to you, Madam Acting Deputy President Moore, and as you would very well know, the Senate Community Affairs Legislation Committee, of which I am a member, conducted two inquiries into this legislation. We did not do that for lack of something to do; we did that because the first piece of legislation that was brought to us was in many ways unsatisfactory and, in fact, was being changed as we were inquiring into it. The regulations which went with that legislation were not available for either the first or second inquiry that we conducted. Our committee has often commented on and often criticised the lack of understanding of the regulations that underpin the laws being made. That was one of the biggest problems with this process.

I would like to join Senator Adams in congratulating the women of Australia—the mothers, the mothers-to-be and the midwives—on their extraordinary reaction to what they saw as an attack on their rights. In the second inquiry, as Senator Fierravanti-Wells pointed out, over 900 submissions were received in a very short time as well as hundreds of form letters and other individual letters. The first inquiry we held received just under 2,000 submissions, again in quite a short period because at the time the government was telling us that it was urgent that we complete the inquiry and get the legislation passed. Those submissions were received primarily from midwives who provide home birth services and of whom we know there are only about 200 in Australia—so do the sums on that—from parents and from organisations that support homebirths. In that first inquiry they were faced with a mishmash of legislation, the consequences of which were completely unknown.

The outline of this legislation would have meant that privately practising midwives performing home births would to all intents and purposes have become quasi-illegal. They would not have been able to have professional indemnity, and without professional indemnity they could not have been registered under the proposed National Registration and Accreditation Scheme for the Health Professions and therefore, if they had practised, they would have been practising completely outside the system. As Senator Adams pointed out, this would have meant that about 200 independent midwives could have been deregistered when this scheme came into play on 1 July 2010 and that if they had continued working they may very well have been fined up to $30,000 each.

Having met the state and territory health ministers, Minister Roxon announced a two-year exemption from holding indemnity insurance for privately practising midwives who could not obtain cover for attending a homebirths in September last year, which was after the first reporting period. So they have a two-year ‘amnesty’, for want of a better word, until June 2012 while the minister works at what to do. Minister Roxon was quoted at the time as having said:

I was concerned that as an unintended consequence of the national registration and accreditation process that homebirthing may be driven underground, that that would not be a good outcome.

It is something of a minor understatement, I would have thought, to suggest ‘that that would not be a good outcome’. At the same time, that phrase ‘unintended consequences’ comes up again as the government seeks to suggest that legislation is urgent and necessary without having done the homework. The government adds insult to injury by suggesting, as Senator Parry outlined earlier, that the coalition has in any way been responsible for the slowness of this legislation being passed. That is absolutely laughable and, I would suggest, unethical. We are not the ones who developed this legislation; we are the ones who pointed out that it was poorly developed and that no one had a clue what it was going to be like when it was implemented. So at least we got through that first hiatus and got the amnesty in place so that midwives can, at least until June 2012, go back to practising the way they have been, by which time one hopes that the minister will have decided how to deal with this issue.

I must admit that I am somewhat startled by some aspects of this debate. This government claims to have something of a monopoly on being pro-woman, but I do not think that this bill in its first draft or even, given the uncertainties and concerns, in its second draft, could be considered in any way pro-woman. Minister Roxon’s talk about the ‘unintended consequences’ without having thought about what they mean is neither reasonable nor acceptable. Ms Justine Caines of Homebirth Australia in the evidence she gave, I believe, to the second inquiry—I am starting to get a bit confused here, Madam Deputy President—said:

We have no problem with the national registration. Some in our world—She means the home birth world—have said, ‘there shouldn’t be a requirement to have indemnity insurance.’ Well, to me, indemnity insurance is a professional requirement but also, very much, a consumer right.

That is the point that I think has been completely missing from any of the discussion that this government has had around this bill. Indemnity insurance is a consumer right within what should be a well-developed, professional, well-regulated health system. Pregnant women are not sick. I think that is a point that needs to be made over and over again. Pregnant women, their partners and other members of their families that they choose to involve should be able to have their child where they choose. Of course we must have requirements in place so that if there are any difficulties or problems they can be dealt with by medical intervention. But women for a very long time have been having children without medical intervention.

I must admit that I was not aware until after the did this inquiry—I do not have the same depth of experience as Senator Adams on the topic of midwifery; my only claim here can be having given birth to three children—of the practice of free birthing. In home births a medical professional, generally a midwife, is involved in both the pregnancy and the delivery of the baby, while free births are conducted without that involvement. There may be a doula—someone who has some basic knowledge or who has helped other people to deliver babies—which is the sort of midwife you may have had 200 or 300 years ago. Often these babies are delivered without the assistance of anyone with any medical experience.

I personally find the idea of a free birth quite worrying, but some women choose to do that. What we do is lump together the statistics about homebirths and free births and suggest that the dangers represented by free births are the same whether you have a midwife or the next-door neighbour helping. This of course is not the case and we need to clarify this. One of the things that Senator Adams and I, as the coalition senators in the first inquiry, suggested was that we needed a more wide-ranging inquiry into the topic of homebirths. It is not well understood in Australia because, in my view, the topic has been taken over by the medical profession. The medical model of how to go about a pregnancy has been the dominant model in our country. I do not think that should happen any longer. We need to recognise that women choose. They should have the choice and will have the choice irrespective of what our laws say about where they have a child. I cannot quite imagine the situation where we will start arresting women at 8½ months pregnancy and take them off to have births according to the way the AMA thinks that all births should be conducted. It is not on, it is not reasonable and it is condescending.

There were some very serious concerns about the way the medical profession presented a number of their problems. They had concerns about nurse practitioners having prescribing rights; they had concerns about nurse practitioners having referral rights; they had concerns about midwives having referring rights. The view was that it should always go back to a GP who would be the case manager, irrespective of the wishes of the women involved, particularly in terms of pregnancy. It was interesting to get an insight into why some women simply do not want to go to hospital to have a baby. It came back to their previous experiences in hospitals. Some of them were just not going to darken the door of a hospital again, no matter what, and there is no way we can force them to.

At the same time we have done very little to encourage the development of birthing centres. These are generally very small and overbooked. People are very lucky to get the chance to have this sort of halfway access—halfway between a homebirth and having a baby in a full hospital setting. We have done nothing there. That is partly because it has not been encouraged. In fact, it has been actively discouraged by many of the doctors involved in the industry. I hate the idea that we might turn this into something like male doctors versus women midwives or pregnant women, but at times there was a sense in the inquiry that professionals have had control of this business—let’s call it women’s business, shall we—for a long time and have been very reluctant to share it. They had used all manner of excuses to stop the development of sharing. In some cases what they did was quite condescending. Suggesting that a trained midwife, who was a member of the college, needed the oversight of a GP to know her job is offensive and wrong. Midwives have a very rigorous accreditation system. It requires that midwives work in a collaborative way with others in the medical profession and the health profession, and that happens. It does not require doctors telling midwives that they need a collaborative arrangement for this to happen, but the problem has not gone away. It seems to me that, until there has been a certain amount of more pressure applied and a certain level of success achieved by midwives and nurse practitioners doing the job that we need them to do, we will not get better action in this area.

I hope that we will simply have the evidence to suggest that the concerns of GPs, obstetricians and gynaecologists that we will have an epidemic of over-referring, an epidemic of overprescribing and an epidemic of poor outcomes in pregnancies will prove to be completely wrong and that the women who have done an extremely good job for many years in assisting women to give birth will continue to do so. There is of course another aspect to this. For a start, homebirths, if they are healthy and safe—and, of course, the job any midwife would want to undertake would be to ensure that was going to be the case or they would refer the woman to a hospital if it were not—are much cheaper than hospital births. They do not use the same health resources that hospital births do. Not only that but, given the right encouragement, there will be more than sufficient midwives available to assist women who want to have their pregnancies dealt with outside of a full hospital setting.

We have a shortage of obstetricians and gynaecologists—we know this. We have a shortage of most specialists. I heard today, in fact, that there is a two-year waiting list to see a rheumatologist in Townsville. I know that is not entirely relevant to this topic, but there are not enough GPs, obstetricians and gynaecologists to go around, so further developing the existing resources of midwives and nurse practitioners would make economic and sensible use of resources rather than simply fighting to ensure that a monopoly is maintained in a particular area.

The other question, as I think Senator Macdonald mentioned, was the problems for women in rural and remote areas. I have spoken at length with a group of women from the state electorate of Southern Downs in Queensland—an electorate represented by Mr Lawrence Springborg, who is very supportive of the women who came to see me and whom I also spoke to about this problem. If you live a long way out of town, what is your chance of having a baby delivered by an obstetrician and gynaecologist? If you live a long way out of a small town, your chances are even less. The women of the Southern Downs were concerned that people had to come to town one week, perhaps two weeks early and wait to have their baby.

Photo of Judith AdamsJudith Adams (WA, Liberal Party) Share this | | Hansard source


Photo of Sue BoyceSue Boyce (Queensland, Liberal Party) Share this | | Hansard source

Four weeks in some cases, Senator Adams tells me, so that they could use this medical assistance to have their baby. But these women wanted that to be the default position. They only wanted to do that if some harm was likely to happen to themselves or to their baby. They are very sensible and, in the main, very fit, active women that we are talking about. They are farmers. They are not going to risk their child, but they are fit healthy women. They want to have a midwife who can assist them and who can be confident that she is not going to be sued by anybody and that she can do the job that needs to be done—and that there will be more midwives coming up to replace those as people age. This is a constant problem in many of our not just remote areas but smaller rural areas where it is difficult to get a GP and where families have to be broken up often for weeks and weeks on end—four weeks as Senator Adams mentioned—so that the baby can be born in a venue considered to be medically suitable surroundings.

The other group that is particularly affected by this problem is Aboriginal women. It has been put to me that many Aboriginal women are having babies without any assistance whatsoever except from older women in their group. They are simply frightened to see obstetricians, gynaecologists and GPs who are, in the main, white and obviously strange and obviously are going to examine them in what could be considered culturally inappropriate ways without any training to support them in undertaking that examination. One of our solutions is for there to be more Indigenous doctors—GPs, obstetricians and gynaecologists—but it is not just about having more. It is also about recognising that in some cultures, and the Aboriginal culture qualifies because of the remoteness from hospitals of many Aboriginal people, the remoteness and cultural sensitivity mean that people would be far more comfortable with a midwife to deliver the child, a midwife to support them and a midwife to accompany them if in the unlikely circumstance they needed to go to a hospital for that delivery to take place. The coalition will be supporting this legislation because it is an improvement on where we have been. We hope that we can have more and better amendments for this legislation as the program proceeds.

9:26 pm

Photo of Steve FieldingSteve Fielding (Victoria, Family First Party) Share this | | Hansard source

I will speak generally on health to start with, as these bills are related to health, and then I will move directly on to the Health Legislation Amendment (Midwives and Nurse Practitioners) Bill 2009 and related bills. Australia has a health system that is on life support at the moment. We have a health system that is broken. Just months ago, we had a major report put out by the National Health and Hospitals Reform Commission which essentially said the same thing. The facts speak for themselves. There are nearly 90,000 patients on public surgery waiting lists. There are 70 per cent of emergency patients who are forced to spend more than eight hours waiting for a bed. The third point is that the average waiting time for elective surgery has increased in most states and is still a real concern.

I have lost count of the number of times that the Prime Minister and the Minister for Health and Ageing have been snapped by the cameras, yet there is still a massive shortage of doctors across the country, particularly in rural and regional areas. The Rudd government is actually going backwards, not forwards, when it comes to health. In 2007, the Labor Party went to the election promising Australians they would fix the healthcare system and would take it over by the middle of the year if it was still stuffed. Guess what? It is still stuffed. It cannot even get its health takeover right. The Rudd government’s plan for a federal takeover is half-baked. It is not a real takeover. It is just rearranging the deckchairs. The Rudd government has proposed a 60-40 funding split, which is a change from a 40-60 funding split. That is not a takeover; that is just rearranging the split between the federal government and the states. The Rudd government has once again overpromised and underdelivered when it comes to health.

The legislation before us now is, once again, proof of how the Rudd government has mismanaged the health system. The legislation contains some good initiatives but also contains some bandaid solutions to our massive health problems that the Rudd government just does not seem to want to address. The legislation before the parliament will see nurse practitioners prescribing pathology and referral rights almost equivalent to that of a GP. I am not against nurse practitioners, but what I am against is the Rudd government using these supernurses to deal with the fact that we do not have enough GPs. Before Family First kicked up a fuss that these supernurses were going to be allowed to operate without the supervision of a GP and without the need for any collaborative agreement with doctors’ clinics, nurse practitioners were going to be able to refer patients to specialists without having any involvement from GPs. Thankfully, common sense has now prevailed and the government has realised that this kind of health reform is only going to fragment the health services even further and end up costing the health system more because it will lead to multiple consultations and claims. The government has now backtracked on this and has put forward new amendments which will require nurses to enter into a collaborative agreement with a doctor’s clinic.

But despite introducing the requirement for collaborative agreements, there are still some issues with the approach which has been taken by the government to fixing the healthcare system. I am all for increasing the role of nurses in the healthcare system because they are highly skilled health professionals who are certainly capable of doing more in the primary health team. The expert knowledge and skill level of nurses is often underappreciated in our health system and it is good that we are looking to expand their role in the health system. But I have big concerns about what the government is looking to do—that is, to simply replace GPs with nurses, particularly in towns where there is a GP shortage. The solution to the massive doctor shortage is not to give nurses more responsibility; it is to train more doctors. It is plain and simple and I cannot understand why the government just is not getting the message.

No-one can replace the family GP who knows your history and your health issues. Unfortunately, the government is prescribing people living in the country a second-rate medical treatment. This plan will disadvantage towns in Victoria like Sale or Hamilton, where there are already GP shortages, because families will be forced to see a nurse instead of their family doctor, while their city counterparts can still get to their GP. This is going to create a huge disparity between the country and the city as to the standard of health care. Country people still deserve access to a doctor and the GP must remain the cornerstone of the primary health team and the first port of call for patients.

I want to also touch on another aspect of the bills where I have some real concerns. There is a big problem that needs to be fixed and that is in relation to the government’s treatment of homebirths. Until very recently, the Rudd government was committed to effectively banning homebirths in Australia altogether. The decision to ban homebirths went against all common sense. Under the government’s original plan, midwives were to be banned from assisting with homebirths and any midwife caught breaching the rules would be fined $30,000. The decision to ban homebirths was totally outrageous and was inconsistent with how the healthcare systems in all other parts of the world are allowed to operate. The decision to ban homebirths came out of left field and was without any justification whatsoever because it ran counter to the right of women to choose how they wish to give birth. It is just another example of how the Rudd government is treating Australians like children and trying to tell us what is best for us. It is not up to the government to tell women how or where to give birth; it is up to women to make a choice about this matter.

Numerous studies have shown that for low-risk women with appropriate transfer-to-hospital options available, homebirths are at least as safe as births in hospitals or birth centres. More recently, in April last year, a study comparing the relative safety of homebirths and hospital births found that there was no difference as to death or serious illness among either mothers or their babies. These facts demonstrate that there was never any good reason for the government to intervene and block the choice of women to deliver their babies in a home environment. After rallies outside the minister’s offices in Melbourne and in Canberra, the government was forced into yet another embarrassing backflip and announced that it would grant a two-year suspension to the ban on midwives attending homebirths. The government, with its tail wagging between its legs, was forced to basically admit that it had completely got it wrong and did not have a clue as to what was the best way forward.

The two-year exemption for midwives who attend homebirths is a short-term bandaid solution. The two-year exemption is a temporary measure that does not fix the problem that the government has created for itself. The two-year exemption is nothing more than a delay tactic to silence any critics so that the government can go to the next election pretending that it is doing something about the homebirth issue. The government has known for months about the problems with homebirths and now it claims that it needs two more years to fix the problem. Surely the government knows that Australians are smarter than that. Surely the government does not think that we were all born yesterday. The changes that the government has put forward are not good enough because they do not fix the issue once and for all, and it has had plenty of time to address the issue.

Family First are not interested in a temporary solution. We want a permanent solution that will make sure that women continue to have the right to give birth at home if they want. And what we certainly do not want is for doctors to have the right to veto midwives who want to attend homebirths by refusing to enter into a collaborative agreement with them. The only person that should have the right to decide whether or not they have a homebirth is the pregnant woman in consultation with the primary care people. This is an issue which needs to be addressed by the government and there is no reason why the government cannot maintain collaborative agreements with nurses while still fixing the homebirth issue. The government needs to stop playing games and demonstrate that it is serious about the homebirth issue by putting forward a solution that will solve the problem once and for all rather than deferring it with a bandaid solution.

9:34 pm

Photo of Claire MooreClaire Moore (Queensland, Australian Labor Party) Share this | | Hansard source

This evening we are looking at three separate pieces of legislation, and they are all important in the evolution of our medical system. As has happened consistently from the time that the Health Legislation Amendment (Midwives and Nurse Practitioners) Bill 2009 was brought forward, we have had a concentration of the discussion on the issue of homebirths. And while I, like everybody else in this debate seemingly, will talk about homebirth later in my contribution, I want to put on the record straight away that it is important that we know the legislation in front of us does not do anything to change the status of homebirth in this country. Despite the statements that have been made around the chamber this evening, it is important to know that the legislation which we are discussing this evening does not take away any current rights or make homebirth illegal or more difficult in this country. It is part of the process that we are discussing about the way a range of legislation will operate in our community into the future. However, I am disappointed that so many people throughout this debate have continued to create some kind of scare campaign and have not looked at what we are considering this evening. That does not make it any easier to make people in the wider community understand what exactly is going on.

What has happened with the legislation before us is that we now have a major breakthrough, a major move forward in the way that nurse practitioners and midwives will be treated in our health system from the end of June 2010. It is something that we need to think about because the discussion about the professional skills and the involvement of nurses in our health system is one that has been going on for many years. Through this legislation the government, our government, with the support of the opposition, has been able to say that with appropriate skills and training, with that recognised, and with the regulations imposed, we will be able to come back into this place, through disallowable instruments, and we will be able to allow practising midwives and practising nurse practitioners in our country to be able to use the PBS and the MBS systems most effectively in our health system.

This is a major achievement and one which has been celebrated and recognised by people across the country. Go to the evidence we received in the Senate Community Affairs Committee and note the pride with which so many people from the nursing professions were able to say that this is something for which they have been working and this is something which we have now achieved in our community for the first time. It acknowledges professional skill. It looks at the role that nurse practitioners and midwives can take in our wider health system. It does not create a two-tier health system, which is another scare tactic that has been used in this debate tonight. There is no attempt to create a two-tier health system in this country.

What we are doing is looking across the community, looking at what the available skills are and looking at the professionalism and the strong cooperative arrangements that are present to ensure that we have the best possible health system that reaches people across all our communities and in all parts of our country. This is not a contest between people with different sets of skills; it is a celebration of the different values of the skills and of using them together in our system. The passing, which I am very pleased to hear is going to occur, of the Health Legislation Amendment (Midwives and Nurse Practitioners) Bill 2009 will achieve this outcome. That is one step along the road to an ever-evolving health system. But if we have people who are continuing, for whatever reason, to create conflict or to create contest then it will take away the value of the practitioners who are seeking to work. Encouraging our people, our nurse practitioners and our qualified midwives with advanced skills to use the PBS and MBS systems most effectively to ensure that they are able to prescribe medication appropriate to their skills area, to be able to refer appropriately according to their skills area and to work in cooperative arrangements with other professionals at all levels will create a stronger, more flexible and better health system for all of us.

Those opposite are trying to create some kind of scare that we are going to be trading skills off against each other and that some parts of the country will not be able to use or have access to particular professionals. That is just not true. What we have before us is a bill that ensures skills will be recognised, that people will be able to practise effectively for the betterment of all of us, that resources will be used more effectively and that we will be able to celebrate and collaborate together.

The Midwife Professional Indemnity (Commonwealth Contribution) Scheme Bill 2009, which we are looking at tonight, is, again, something which is long overdue. Whilst I do acknowledge so many contributions in this debate that talk about why we need to move more quickly, why we should be including all aspects in tonight’s legislation and why we have failed to include homebirths in this process, I want to remind the people who are involved in this debate that midwives have been without effective professional insurance since 2002 in this country and there has been no effort made across this chamber to ensure that that is addressed. Through this legislation, there has been an attempt. There are some processes which need to be addressed. There needs to be much more discussion between the various groups involved in this process, including the professional groups and, most assuredly, the insurance industry.

Through this legislation, the threshold achievement has been reached, which allows practising midwives in this country to access professional medical insurance with government support, which has been lost in much of the debate that we have had up until this time. If you look at the history of medical indemnity insurance in this country, in 2001-02, when there were so many problems, the government stepped in to provide support for the medical profession. At that time there was no support for midwives in that process. They have been effectively operating without support since that time. This legislation addresses that. With people and the professional colleges working together, we will be able to ensure that there will be that protection for midwives.

We have heard before in this debate about the process around homebirths. I knew we would come to it because it took up a considerable part of all the debate that we had in the two Senate Community Affairs Committee inquiries that were formed around the legislation. When you have a look at the committee reports, while they were looking at three pieces of legislation, they seemed to be concentrating exclusively on the role of homebirth. It is an important fact that many women came to those inquiries and said that this was a choice they wanted to make.

It is also an important fact that people from the various parts of the medical professions—doctors, nurses and people who worked in the hospital system—also came forth and gave their ideas about how we should move effectively forward to ensure that we have the safest possible birthing arrangements for all women in this country. I applaud the fact that these people were able to come forward and talk together very openly about a shared interest—and there is a shared interest. Overwhelmingly, people talked to us consistently about the need for safety and security and the involvement of the people who choose to be involved, such as family and medical practitioners.

People talked about the fact that there needed to be cooperation and collaboration, a word which was used much and which I value. We have not formally been able to pull that completely together at this stage but we have a process for ensuring that does occur. It is something that has never happened before in this country. What we have, through the processes which the government has put together, is continuing work on the national registration scheme, which is bringing together the professional colleges to ensure appropriate registration for medical practitioners of all kinds in our community. We also have the ongoing work of the Victorian government, which is looking to put together a framework for professional practice and which will be able to show the effect of midwives and doctors working together to see how best that can be defined. That has been an agreed process and it has been a cooperative process.

The Maternity Services Advisory Group was formed to provide information to the government about the whole range of issues which we need to address on safe birthing in this country and it has been working extraordinarily hard for the last several months, once again, to come up with an agreed solution. That is what will be involved in the regulations, which will come back to this place as disallowable instruments, to put this in place.

There has not been any attempt to close down any of this debate. In fact, what the government has done is encourage it to occur, but for the last few years this particular process has not been in place. The legislation, through a combination of the NRAS—the National Registration and Accreditation Scheme—and this process, which is looking at professional indemnity for midwives and people who are working in the system, will be able to come up with the outcome which so many people have sought. Many people have given us evidence and put forward their views in the various Senate community affairs committees, and senators and members in this place have received many emails and contributions from people talking about their birthing rights.

We have heard the views of a number of senators tonight about what the future of this process should be. There must be an outcome. There is a genuine commitment from all the people who have been involved to ensure that there is an outcome. This particular legislation provides movement forward. It does not determine what the regulations are going to be; that will come back to this place. There is no way that there is going to be a disconnect between the regulations which support this legislation and the legislation which is before us this evening. Again, the role of the Senate will be to consider those regulations through the various processes, to ensure that they once again meet the needs of consumer groups, medical groups and of the government and funding groups. It is a simple stage of our medical process.

There continues to be genuine interest in this process, as there must be. We have a collaborative arrangement between the state governments and the federal government looking at how we can bring this to a conclusion through COAG, because so much of what happens in maternity services at this stage is the responsibility of state governments. I want to put on record this evening the amazing welcome and support that I had from a number of state hospitals in Queensland, when I visited their midwifery services to see how they operate. I want to congratulate and thank the staff members in the midwifery section of the Goondiwindi Hospital, where I spent many hours talking about the way midwifery services are operating in that place, and I saw a genuine collaborative service.

I also want to congratulate the number of people—particularly from the private midwives group—who have worked tirelessly to ensure that the needs of their members are met and are put into place in any legislation that comes forward. There is no doubt that there will be an outcome because there is so much goodwill and determination. It is not a competition or a conspiracy between different parts of the medical profession. Many people have moved a long way from when this debate began and I think that should be acknowledged. We have before us three pieces of legislation, none of which make anything that is happening illegal and all of which provide an incredible breakthrough for people with professional skills. So many people will benefit from now having greater access to professional skills in our hospitals and health system.

9:48 pm

Photo of Nick XenophonNick Xenophon (SA, Independent) Share this | | Hansard source

There is no question that the very debate we are having in this chamber tonight has similarly been held in homes, cafes, offices and around the water cooler by Australians around the country—men and women alike—and by those with or without children. I certainly know that in my own office we have had some extensive discussions that have, at times, been robust about this very issue. There are so many aspects to this debate: the right for a woman to decide how to give birth; the right for a child to be born safely into this world; the purported risks of both home births and medical intervention; and the claimed benefits of natural birth and of delivery in hospital, to name but a few. In many ways, this debate has gone far beyond these pieces of legislation. While the debate in the media has certainly been focused on the impact these bills will have on home births, this legislation will impact on midwifery, full stop.

Over the past few months I have been contacted by dozens of families, as I am sure many of my colleagues have, who want to share their experiences of pregnancy and of delivering their baby at home with a midwife. In fact, I have had literally hundreds of emails on this particular topic. They have told me about the trust and bond they shared with their midwife throughout their pregnancy and how safe they felt during the delivery of their child. (Time expired)