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Government Response to the Senate Community Affairs References Committee Report on Childbirth Procedures “Rocking the Cradle”

INTRODUCTION

The Government provides the following response welcomes the opportunity to respon d to the Senate Community Affairs References Committee Report “Rocking the Cradle - A Report into Childbirth Procedures”. The Report provides a n national overview of antenatal, birthing and postnatal phases of maternal and infant care in childbirth across Australia and builds on earlier reports at state and national levels relating to maternity services. Most of the views and recommendations of the Report however, are in the realm of State and Territory Government responsibilities or comment upon clinical decisions. The Government does not consider that this form of inquiry is best suited to assess quality, safety and relevance in clinical matters.

The Committee found that Australia has a high rate of obstetric intervention compared to some other developed countries. However, as the Report notes, intervention rates vary considerably between countries. The Committee found that there is widespread satisfaction with the quality of birthing services available in this country.

The Report draws attention to the significant improvements achieved in recent decades in maternal and infant mortality in Australia, this country’s rates now comparing favourably with those of other first world countries. Having a baby in Australia, by any standards, is a safe event for most women.

The Report notes that many factors have contributed to the dramatic improvements in maternal and infant mortality in Australia and highlights the role that population health measures have played alongside other factors such as medical advances in treatment and application of technology.

Government Approaches to Improving Australia’s Health System

The Government is funding and driving programs of health system improvement on a scale greater than has been seen in Australia before. Criteria of quality, safety, relevance, choice, equity of access and effectiveness based on evidence are paramount. This Response to the Report outlines some relevant initiatives.

The Government’s view however, is that a vital element of these initiatives has been to foster decision-making at the level and area most suited to meeting regional, local community or individual needs.

Needy Populations

The Report draws attention to the fact that aggregate data does not tell the whole story. There are particular efforts in place to improve outcomes in childbirth for certain population groups, including Indigenous peoples, and those living in rural and remote Australia.

People Living in Rural and Remote Areas

Improving the delivery of health and community services to Australians living in rural and remote regions is a major priority for the Government. In the 2000-01 Budget the Government introduced a $562 million Regional Health Strategy to improve health services in rural and regional Australia and to significantly increase the rural health workforce. Many of these measures are expected to have an impact on rural women receiving antenatal care ie:

• $49.5 million over four years to increase the range of allied health services available to rural and regional communities. This will enable rural GPs to employ nurses and allied health professionals to meet locally identified need.

• $48.4 million over four years for a rural specialist outreach program, which will allow rural residents to receive some specialist services in their own communities, rather than having to travel long distances.

• $68.9 million to expand the Regional Health Services Program introduced in the previous Budget. These centres draw together health, aged care and other community services to a central location providing a flexible mix of services based on community need.

• $102.1 million over four years to increase the number of GP registrars in rural areas.

Other measures announced in the Budget will enhance rural education and training for health professionals through additional University Departments of Rural Health, the establishment of additional clinical schools in rural and regional areas, and the provision of additional training scholarships.

Aboriginal and Torres Strait Islander People

The Government continues to deliver on its commitment to improve the health status of Aboriginal and Torres Strait Islander people with a focus on expanding primary health care services. Building on initiatives announced in previous Budgets, the 1999 Budget boosted Commonwealth funding for this purpose by $100 million over four years.

The greater part of this funding ($78.8 million) is being used to improve access for Aboriginal and Torres Strait Islander peoples to primary health care through the Primary Health Care Access Program. This initiative will establish a framework for the coordinated expansion of comprehensive health care services including clinical care, illness prevention and early intervention activities.

For the first time, national performance indicators and targets for Aboriginal and Torres Strait Islander Health have been agreed to by all Australian Health Ministers. The indicators include measures relating to still births, infant deaths and low birth weight among Indigenous children.

With Commonwealth leadership, innovative service delivery models are being developed in collaboration with the Aboriginal controlled health sector, State and Territory Governments, General Practice and other health professionals. These will build on current services and help integrate mainstream providers in delivering services, including maternal and child health services, to Aboriginal and Torres Strait Islander peoples. This will mean that the best mix of care is available to meet the health care needs of these clearly disadvantaged people.

Leadership in Health

The Commonwealth’s role in health is to provide strong national leadership in a collaborative process of health sector reform aimed at developing a strong population health approach to disease prevention, health promotion and education; to improve the availability of high quality, integrated and cost effective services with a strong consumer focus; and to develop a strong sound evidence base to support population health measures and clinical care and treatment.

The Commonwealth provides leadership through working collaboratively with stakeholders to develop broad policy frameworks and through both the provision of funding and the purchase of services.

The Government’s reform agenda is consistent with the main thrust, and many of the recommendations, of “Rocking the Cradle” in that it aims to enhance continuity in care for consumers, to remove artificial barriers, and to encourage collaborative arrangements between health care providers at the community level.

Private Health Insurance

The Government is continuing to improve the attractiveness of private health insurance to the Australian population through key reforms that address affordability of premiums, innovative products and structural reform of the sector. These reforms increase the level of patient choice in health care for all Australians.

The 30% rebate on health insurance premiums has addressed the issue of affordability for all Australians.

Lifetime Health Cover builds on the existing community rating system through a new, fairer and workable lifetime approach to health insurance cover.

The Government can also increase the attractiveness of the private health insurance product through regulatory change. Steps have been taken to expand the models of care available to the privately insured that have previously been unavailable such as early discharge and hospital in the home care.

Industry efficiency benefits patients and their choice of care. A consumer strategy focusing on greater patient education and information is underway. Key features include a statement of what can be expected when holding private health cover and a trial of a consumer hotline are the first steps.

Through these and other reforms, the Government is active in ensuring the Australian population has a choice in health care. This is of particular importance with respect to all aspects of care during pregnancy and childbirth.

Alternative Birthing Services

The Report commends the contribution that the Commonwealth has made towards the promotion of consumer choice in birthing services through providing incentive funds for the establishment of birthing centres in States and Territories under the Alternative Birthing Service Program. ABSP funds also contributed towards the establishment of culturally appropriate birthing services for Indigenous women. The Report places particular emphasis on the provision of culturally appropriate and comprehensive antenatal information for individual women according to their ethnicity and cultural backgrounds.

Evidence Base

The Government has given priority to investing in research and information which will maximise the quality of services and the effectiveness of the health system.

The Australian Council for Safety and Quality in Health Care has recently been established by all Health Ministers as a means of coordinating national actions to build upon the many safety and quality improvement activities taking place around Australia. The new Council is a national partnership between governments, health care providers and consumers. It will contribute to improvements in the safety and quality of care for patients and help reduce the risk of adverse events.

The National Institute of Clinical Studies, which will be established by the Commonwealth Government later this year, will also play a role in improving the quality of health care in Australia and ensuring the health system is underpinned by world’s best clinical practice. The Institute will work closely with stakeholders to identify, develop and promote best clinical practice throughout the public and private sectors.

The Government has also invested in improvements to national information and data with a major focus being on the role of the Australian Institute of Health and Welfare. One of the particular activities that are funded through the auspices of AIHW is the National Perinatal Statistics Unit (NPSU). The NPSU has developed a number of data systems on women’s reproductive health services and pregnancy outcomes services that cover the period from conception to birth and up to one year. The NPSU publishes regular reports on mothers and babies including a separate report on Indigenous mothers and babies.

Research into the effectiveness of interventions, the development of best practice guidelines by the National Health and Medical Research Council and the co-sponsorship of the Australasian Cochrane Centre by the Government are contributing to the increase of knowledge and improving the basis for decision making.

Commonwealth Funding Assistance to State and Territory Governments for Health Care

For the greater part, the Report recommendations are concerned with service delivery issues which are the responsibility of State and Territory Governments. This observation was made in the minority report by Government Senators and included the comment that “the Federal Government should not be dictating to the States how they should be running services that fall within their responsibilities.”

This view is consistent with the recommendations of the Joint Committee of Public Accounts, a statutory committee of the Australian Parliament. In Report No 342 of November 1995 the JCPA Chairman stated:

The Committee believes that the Commonwealth needs to have a clearer focus on strategic planning and articulating SSP (Specific Purpose Payment) objectives in the community… the Commonwealth should progressively disengage itself from SPP micro-management, leaving this task to state governments and other non-Commonwealth parties to SPP agreements. Primary accountability (by funded parties) to the Commonwealth should increasingly be for outcomes achieved rather than for inputs and processes.

The Committee went further in Recommendation 3 of the same Report ie:

Commonwealth departments administering SPPs involving more than one level of government should ensure that the SPP agreements do not prescribe the method of service delivery by another level of government.

Public Health Outcome Funding Agreements

In line with the JCPA recommendations the Commonwealth Government contributes towards the capacity of individual States and Territories to maintain and improve the general level of Australia’s health through broad Public Health Outcome Funding Agreements (PHOFAs). The base funding in the PHOFAs resulted from the broadbanding of Commonwealth funding to States and Territories for eight established public health programs (SPPs), including the National Women’s Health Program and the Alternative Birthing Services Program.

The current PHOFAs are for a five-year period, 1999-2004 and will provide in excess of $900 million to States and Territories during that time. They focus strategically on maintenance of effort through the specification of annual performance reporting requirements for population health outcomes relating to the incorporated SPPs. State and Territory Offices of Health and Aged Care collaborate with State and Territory Health Authorities in monitoring and reporting performance under the PHOFAs at the local level. The annual performance reports from the States and Territories are published on the website of the Commonwealth Department of Health and Aged Care.

These funding Agreements are designed to provide States and Territories with the flexibility to ‘mix and match’ Commonwealth financial assistance to meet the varying needs of their respective populations while at the same time ensuring that the States and Territories remain part of a nationally coordinated effort in areas of high national priority.

Funding of Services

Commonwealth funding for public hospitals is provided through the 1998-2003 Australian Health Care Agreements (AHCAs). The Agreements are a vehicle both for committing Commonwealth funds to public hospital services delivered by the State and Territory Governments, and for instigating reform in the funding arrangements for acute health services.

Under the AHCAs the Commonwealth is providing substantial financial assistance to the States and Territories to meet the cost of public hospital services. Over the life of the Agreements, the States and Territories will receive total funding of around $31.3 billion, representing a 25 percent real increase in funding over the five years to 2002-03. State and TerritoryGovernments have responsibility for, and indeed, are in the best position to, make decisions about the allocation of AHCA funding to public hospitals for particular purposes, including for the provision of obstetric services to women in rural and remote areas.

In addition to the core funding arrangements, the AHCAs also commit the Commonwealth and the States and Territories to working in partnership to achieve agreed health service delivery reform and set out a number of specific areas where reform of the health system and its funding may be advanced, including:

• integration of care through measure and share arrangements;
• information technology reform;
• more responsive funding;
• additional funding in the area of quality improvement and enhancement;
• funding for the establishment of a National Health Development Fund.

The Government is also a major funder of prenatal and birthing care through Medicare payments for a wide range of antenatal, peri-natal and birthing services for pregnant women, apart from those using birthing centres or public patients using hospital based services.

In 1998-99, $57.7 million was paid in Medicare benefits in respect of 1.55 million obstetrics services. In addition, in 1998-99 $38.6 million was paid in Medicare benefits in respect of 514,014 ultrasound in pregnancy services.

Private health insurers are also a major source of funding for all aspects of care during pregnancy and childbirth. While an indepth consideration of the role of the private insurance providers was not included in the Committee’s Terms of Reference, Committee members did acknowledge that the availability of private health insurance is providing many women with real options in antenatal care and birthing services.

Conclusion

Initiatives of this Government across the spectrum of funding of States and Territories, private health insurance, rural health, Indigenous health and quality in health provision have established an environment in which quality, choice, equity and effectiveness in health service provision can flourish as never before. In this environment, the Government is confident that the relevant decision-makers can assess the recommendations of the Report “Rocking the Cradle - A Report into Childbirth Procedures.”.

While the delivery of medical and midwifery services is the responsibility of State and Territory health authorities, as well as clinicians in their support of patients, the Government has endeavoured as far as possible to provide responses to individual recommendations in this Report from the Opposition Members of the Senate Community Affairs References Committee. These responses are set out below.

(Note that a sequential numbering system has been added to the set of recommendations to assist in identifying the responses.)

CHAPTER 2: ANTENATAL CARE

Recommendation 1:

The Commmitte recommends that the Commonwealth Government work with State Governments to implement the recommendations of the National Health and Medical Research Council as they relate to continuity of care and shared care during pregnancy and birth.

The Government draws on the National Health and Medical Research Council (NHMRC) guidelines as part of its evidence base for national strategic planning across the full spectrum of health care including obstetric care.

The range of antenatal services available in Australia is extensive and Australian women have generally enjoyed access to a high standard of care during pregnancy and birthing. Maternity services are often based on a traditional model of obstetric care, with women in hospital being cared for by a team headed by a general practitioner or specialist obstetrician.

The Commonwealth is currently working with the States and Territories to provide better integration of care through the following provisions in the Australian Health Care Agreements for patients using public hospital services and through other mechanisms to ensure integrated approaches to population health and primary health care.

Australian Health Care Agreements

• National Health Development Fund

The National Health Development Fund (NHDF) has been established to foster innovation in hospital services provision through funding projects at the regional or State wide scale that improve:

• patient outcomes;
• efficiency and effectiveness in, or reduce the demand for, the delivery of public hospital services; and
• integration of care between public hospital services and broader health and community care services.

Approximately $253 million in Commonwealth funding is available over the life of the Agreements for projects that bring about long term improvements in health care delivery.

Under the Agreements, each State and Territory is responsible for bringing forward a proposed strategic plan for use of the NDHP. Although each plan is subject to the joint agreement of the Minister for Health and Aged Care and the relevant State or Territory health minister, decisions relating to the initiatives that are brought forward in strategic plans rest with each State and Territory Government.

Although there has not been a specific focus on maternity services within the NDHP, given that NDHP projects are designed to act as catalysts for organisation-wide improvements in the quality and effectiveness of service delivery, it is reasonable to assume that midwifery patients accessing these hospitals have benefited from initiatives funded by the program.

• Measure and Share Provisions

Under the Measure and Share provisions of the Australian Health Care Agreements the Commonwealth and the States and Territories have agreed to work on proposals for improving the integration of service delivery by removing artificial Commonwealth/State financial barriers. These “measure and share” arrangements are predicated on changes in service delivery improving patient outcomes and/or increasing the cost-effectiveness of care delivery. It is anticipated that many developments in this area will be informed by the coordinated care trials that are currently under way across the country .

By agreeing a method to address the impact on funding of changes in service delivery the Agreements facilitate innovation and improvement in the delivery of public hospital services in a tangible way.

Decisions relating to the aspects of service delivery arrangements that are brought forward for consideration in relation to measure and share proposals remain with State and Territory Governments.

The National Demonstration Hospitals Program (NDHP)

Since 1995 the NDHP has funded time-limited, demonstration projects in selected hospitals to explore and develop new approaches to the organisation and delivery of acute care service.

Of the projects funded by the NDHP in major tertiary teaching hospitals over two thirds have taken place in hospitals with a substantial component of midwifery patients. Of the other 60 projects funded by the program, over three quarters have been in hospitals that provide care for some midwifery patients.

Divisions of General Practice Strategy

A sizeable number of Divisions of General Practice are involved in shared care arrangements for obstetric patients, such as the Brisbane Southside Collaboration referred to in the earlier Submission to the Committee from the Department of Health and Aged Care. This Collaboration is a linked project between a GP Division and a major hospital as part of the National Demonstration Hospitals Program. The focus is on piloting antenatal and postnatal shared care and in its evaluation information will be sought about patient and provider satisfaction as well as clinical outcomes.

Recommendation 2:

The Committee recommends that all pregnant women in Australia be provided with a maternity record by their principal carer giving details of their health as it relates to their pregnancy and any test results or treatment, with a duplicate to be held by their principal carer.

The issue of health consumer access to personal health information is an important one and one which this Government is addressing within the context of its planned Privacy Amendment (Private Sector) Bill 2000, which includes a commitment to consumer access to personal information.

Many Divisions of General Practice have programs targeting obstetric shared care, including several with a focus on antenatal and postnatal shared care. A number of these programs include the use of patient held personal record cards throughout pregnancy. The Government would be interested to see more widespread application of such approaches. Consideration could be given to working with the appropriate Colleges with a view to universal implementation.

The Government therefore would support the provision of a consolidated maternity record to all pregnant women, with participation in the process and content of the record to be agreed between providers and health consumer s.

Recommendation 3:

Commonwealth Government fund major tertiary hospitals to extend the provision of satellite clinics and visiting teams of obstetricians to assist women in rural and remote areas.

The Commonwealth Government is committed to improving access to specialist services in rural and regional Australia. The 2000-01 Budget provides $48.4 million over four years for a rural outreach program for specialist services. This will include incentives and/or travel costs for specialists to conduct outreach specialty work and to act as mentors for local health professionals to help them increase their skills. The program will be implemented in collaboration with the States and Territories, as well as specialist colleges, divisions of general practice and rural workforce agencies. The program will target a range of specialist services and geographical areas based on need.

This initiative complements the existing Commonwealth initiative to establish specialist training posts in rural areas, under which four rural registrar posts in obstetrics and gynaecology were funded in 1999. It also complements the efforts of State and Territory Governments to increase the presence of specialists in rural and regional areas. In addition the Commonwealth has funded a female obstetrician post attached to the University Department of Rural Health in Victoria, to address the needs of Muslim women in the Hume Region.

Recommendation 4:

The Committee recommends that the Office of Aboriginal and Torres Strait Islander Health provide recurrent funding to ensure continuity for existing antenatal programs for Aboriginal and Torres Strait Islander women and to establish new programs in areas of need.

The Government contributes towards the provision of antenatal programs for Indigenous families through its funding of Aboriginal Community Controlled Health Organisations. As outlined in the Introduction, the Commonwealth emphasis is on improved access to primary health care for Aboriginal and Torres Strait Islander people, and will be achieved in two ways:

• expansion of Aboriginal community controlled primary health care services; and
• improved orientation of mainstream services to meet the needs of Aboriginal and Torres Strait Islander people.

Further expansion of community controlled primary health care services for Aboriginal and Torres Strait Islander health is aligned with the continued development of regional planning processes, which are the mechanism for identifying agreed priority areas of need. The expansion of primary health care through the increased federal budget commitment to Aboriginal and Torres Strait Islander health will support the continuation and improved development of ante-natal and post-natal programs in Aboriginal Community Controlled Health Organisations.

Recommendation 5:

The Committee recommends that the Commonwealth Government work with State Governments to reinstate programs to assist women from non English speaking backgrounds to gain access to antenatal services, using funding provided through the Public Health Outcome Funding Agreements.

AND

Recommendation 6:

The Committee recommends that the Commonwealth Government work with State Governments to promote antenatal programs targetted to adolescent mothers. AND

Recommendation 7:

The Committee recommends that the Commonwealth Government work with State Governments to ensure that comprehensive, accurate and objective information is made available to all pregnant women on the antenatal and birth options available to them, with funding provided through the Public Health Outcome Funding Agreements.

AND

Recommendation 8:

The Committee recommends that the Commonwealth Government work with State Governments to ensure that comprehensive, accurate and current information is made available to all principal carers of pregnant women about the antenatal and birth options and services available in their area, with funding provided through the Public Health Outcome Funding Agreements.

As outlined in the Introduction, responsibility for delivery of popu la ltion health measures rests primarily with State and Territory Governments and with Divisions of General Practice and individual GP’s. The Commonwealth has a broad policy leadership and financing role in promoting population health action including the integration of population health within the wider health system. The Commonwealth’s role is to promote integrated services and population health measures. The Public Health Outcome Funding Agreements (PHOFAs) are broadbanded funding arrangements between the Commonwealth and the States and Territories that set out in a single Agreement the ongoing Commonwealth funding provisions for a number of public health programs including the National Women’s Health Program and the Alternative Birthing Services Program.

State and Territory Governments have the flexibiltiy and the responsibility under the PHOFAs to allocate resources according to local priorities and population needs while agreeing to maintain ing effort and report ing annually against agreed national performance indicators set out in the funding agreements. Decisions about funding allocations to women’s health services, including birthing and pregnancy support services are the responsibility of State and Territory health authorities.

Recommendation 9:

The Committee recommends that the Commonwealth Government work with State Governments to ensure that antenatal information is made available to all Indigenous women in a language and format that meets their needs, with funding provided through the Office of Aboriginal and Torres Strait Islander Health.

Through the allocation of resources to establish and maintain comprehensive primary health care services, regional planning processes, and commitment to community consultation, the Office of Aboriginal and Torres Strait Islander Health (OATSIH) supports provision of culturally appropriate information in identified areas of need. In order to be appropriate, information must be locally tailored. OATSIH funded Aboriginal Community Controlled Health Organisations are well placed to contribute to the development and provision of this information. Facilities available through local tertiary health services should be accessible to the Aboriginal community controlled sector to ensure integration of culturally appropriate materials in mainstream health programs as well.

Recommendation 10:

The Committee recommends that the Commonwealth Government work with State Governments to ensure that antenatal information is made available to all women from non English speaking backgrounds in a language and format that meets their needs, with funding provided through the Public Health Outcome Funding Agreements.

See response to recommendations 5,6,7 and 8 above.

Recommendation 11:

The Committee recommends that the National Health and Medical Research Council, in conjunction with professional medical bodies and midwives’ organisations, establish guidelines governing the prior provision of counselling and information on all antenatal screening tests, for adoption and implementation by the professional bodies.

AND

Recommendation 12:

The Committee recommends that the National Health and Medical Research Council, in conjunction with professional medical bodies and midwives’ organisations, establish guidelines governing the provision of counselling and information on the benefits and disadvantages of the various forms of intervention which may be required by women during birth, for adoption and implementation by the professional bodies.

One of the statutory functions of the NHMRC is to inquire into and issue guidelines on the improvement of health, the prevention, diagnosis and treatment of disease and the provision of health care. The Health Advisory Committee (HAC) of NHMRC is the principal mechanism for the development of practice guidelines. Its terms of reference emphasise an evidence-based approach, and HAC has developed formal levels of evidence on which its guidelines are based.

HAC does not normally develop guidelines on the provision of counselling and information, which is more an administrative than a scientific matter. Its role, rather, is one step removed, in assessing the scientific evidence from which sound counselling approaches may be distilled. Illustrative of this is its recent work on the psychosocial aspects of breast cancer, which uses research evidence to highlight the needs of women being diagnosed with breast cancer.

Where issues do not lend themselves to an evidence-based analysis, but nonetheless impinge on practice, HAC may refer them to the relevant professional associations. The newly established Quality and Safety Council, and the National Institute of Clinical Studies, both of which have a strong consumer focus, may also have a broad interest in the development of quality advice for consumers.

The Committee’s recommendation has been referred to the NHMRC for consideration and possible inclusion in its work plan for the 2000 – 2002 triennium.

Recommendation 13:

The Committee recommends that the Commonwealth Government work with State Governments to ensure that adequate and appropriate antenatal education classes are generally available, using funding provided through the Public Health Outcome Funding Agreements.

As outlined in the Introduction and in responses t o See response to recommendations 5,6,7 and 8 above . , the PHOFAs are broad funding agreements designed to give States and Territories flexibility in meeting local needs and priorities whilst maintaining effort in regard to national priorities.

CHAPTER 3: ANTENATAL SCREENING SERVICES

Ultrasound in Pregnancy

The Commonwealth has a strong commitment to ensuring that Australian women have access to high quality, cost effective obstetric ultrasound services through Medicare. The Department of Health and Aged Care is responsible for managing the Medicare funding of ultrasound and other diagnostic imaging services.

As part of this management, the Department has established the Diagnostic Imaging Agreement with the Royal Australian and New Zealand College of Radiologists (RANZCR). The purpose of this agreement is to foster the joint management of Medicare funding for diagnostic imaging between the Commonwealth and the profession. The Agreement is intended to ensure that patients can access high quality, clinically appropriate and affordable diagnostic imaging services.

The Department has introduced a number of initiatives to improve the quality use of pregnancy related ultrasound. These initiatives include funding for the development of accreditation and quality assurance for providers of obstetric ultrasound, the introduction of professional supervision requirements for ultrasound, and referral of new technologies, such as nuchal translucency, to the Medicare Services Advisory Committee (MSAC) for assessment of evidence and appropriateness.

As part of the management of diagnostic imaging, the Department has undertaken a systematic restructure of the Medicare obstetric ultrasound items.

The changes, effective from 1 February 2000, introduce new obstetric ultrasound items that cover the full range of services provided in pregnancy, and that fund these services according to their complexity. New items are provided for early, mid and late pregnancy ultrasound, and for more complex services. The new items also introduce clinical indicators to ensure that ultrasound services are provided when clinically necessary for the good management of the pregnancy.

It is important to recognise that while the Department can make changes to the Medicare obstetric ultrasound items, a significant proportion of obstetric ultrasound is carried out within the public hospital system, and in accordance with the provisions of the AHCAs, decisions relating to service delivery in public hospitals are the responsibility of State and Territory Governments.

Recommendation 14:

The Committee recommends that the National Health and Medical Research Council develop standards for the training of operators of all obstetrical ultrasound equipment and for those who interpret the results of those tests.

The Committee’s recommendation has been referred to NHMRC for consideration and possible inclusion in its work plan for 2000-02 triennium.

The Government has provided nearly $400,000 to the Royal Australian and New Zealand College of Radiologists (RANZCR) over the past 3 years to develop and implement standards for accreditation of medical imaging practices. The College is covering all modalities of medical imaging in this exercise, including obstetrical ultrasound.

In addition, the Government is providing $80,000 to the Australasian Sonographer Accreditation Register (ASAR) to develop, establish and implement a mechanism for the accreditation of Sonography training and education programs.

The Department is also negotiating the provision of $100,000 to the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) and the National Association of Specialist Obstetricians and Gynaecologists (NASOG) for the development of Continuing Medical Education and Quality Assurance Program (CME & QA) requirements for obstetric and gynaecological ultrasound practice.

In recognition of the particular problems facing rural areas, funding is also being provided to the Australian College of Rural and Remote Medicine, to work with the RANZCR and the Royal Australian College of General Practitioners (RACGP), to develop, establish and implement a CME & QA for general practitioners who utilise ultrasound under exemptions contained in the legislation governing ultrasound and payment of Medicare Benefits.

The four major Colleges concerned with obstetric ultrasound have agreed to work with the Government to develop appropriate CME & QA and accreditation standards for adoption by all Colleges.

Recommendation 15:

The Committee recommends that the National Health and Medical Research Council develop guidelines governing the safe use of all obstetrical ultrasound equipment.

The safety of medical service provision is principally a State responsibility. However, the Commonwealth is strongly committed to ensuring that services funded under Medicare are safe, clinically appropriate and reflect best practice, and has introduced initiatives to ensure this. Several of these initiatives impact on the use of obstetric ultrasound equipment. See response to recommendation 14 above also.

Recommendation 16:

The Committee recommends that the National Health and Medical Research Council develop or coordinate the development of evidence based assessments of the efficacy of routine ultrasound scanning in pregnancy and that it conduct a cost benefit analysis of current ultrasound practices.

AND

Recommendation 17:

The Committee recommends that the National Health and Medical Research Council conduct or oversee the conduct of an Australian multicentre trial of nuchal fold screening to determine its efficacy for use among pregnant women generally, and among those considered at particular risk of carrying babies with Down’s Syndrome.

The Medicare Services Advisory Committee (MSAC) is an independent committee which has been established to provide advice to the Minister for Health and Aged Care on the strength of evidence available on new medical technologies and procedures in terms of their safety, effectiveness and cost effectiveness.

The MSAC process involves the rigorous assessment and classification of evidence from available medical research according to the National Health and Medical Research Council (NHMRC) four-point hierarchy of evidence. The findings of MSAC help inform Government decisions about which new medical services should attract funding under Medicare.

MSAC is currently establishing a committee to examine the nuchal translucency test and its use in early pregnancy ultrasound.

Recommendation 18:

The Committee recommends that earlier recommendations relating to the training of operators and the regulation of equipment used in routine ultrasound screening should also apply to nuchal fold screening.

Any action on this recommendation is dependent on the evidence that emerges from the MSAC evaluation of the nuchal translucency test.

CHAPTER 4: CARE DURING BIRTH

Recommendation 19:

The Committee recommends that the Commonwealth Government work with State Governments to ensure the continuation and expansion of hospital birthing centres.

The Government notes the Report’s findings on consumer satisfaction with birthing centres in public hospitals as a service of choice for many pregnant women. The Government also notes the Committee’s support for the expansion of birthing centres as part of the mainstream health system, with funding from hospital budgets. This is a matter for State and Territory Governments to determine in the context of their own budgets. It should be noted however that the Australian Health Care Agreements do not:

• - require State and Territory Governments to ensure the continuation and expansion of hospital birthing services;
• - afford the Commonwealth the authority to raise issues regarding the direction of funds to particular purposes with State and Territory Ministers.

Decisions relating to the allocation of AHCA funding to public hospitals for particular purposes, including for the continuation and expansion of hospital birthing centres, rest with State and Territory Governments.

The Commonwealth provided funding under the Alternative Birthing Services Program to pilot increased options in birthing services including the establishment of new birthing centres. The Alternative Birthing Services Program is one of the broadbanded programs within the PHOFAs. States and Territories are required to provide annual performance reports covering the broadbanded programs, including for example reporting the number of midwife based birthing services established in the publicly funded health care system.

Recommendation 20:

The Committee recommends that the Commonwealth Government continue to fund midwives to assist at home births for women at low risk through the Public Health Outcome Funding Agreements.

See the response to recommendations 5,6,7 and 8 above.

Recommendation 21:

The Committee recommends that the Commonwealth Government work with State Governments to assist Aboriginal and Torres Strait Islander women who have to give birth outside their communities by funding an accompanying family member, with funding provided through their patient transfer assistance schemes.

Funding under the Patient Assisted Travel Scheme (PATS) was transferred to States and Territories who are now responsible for the management and funding of this Scheme. It has been recognised however that the Aboriginal and Torres Strait Islander people’s access has been problematic and yet that the need to travel long distances to give birth and lack of family support is a major issue for Indigenous people in remote locations.

The issue was raised by the National Aboriginal Community Controlled Health Organisation (NACCHO) members at the National Aboriginal and Torres Strait Islander Health Council in 1997 – 98. As a result, the Council referred the matter to the Australian Health Ministers Advisory Council Council (AHMAC) . who, in June 1998, agreed to undertake a review of PATS and its impact on Indigenous people. A report prepared by South Australia was submitted to AHMAC in May 1999. Additional comments were sought from the jurisdictions and the Department provided comment in June 1999. The Department is now awaiting the outcome of AHMAC consideration of this issue. review.

Recommendation 22:

The Committee recommends that the Commonwealth Government, through the Office of Aboriginal and Torres Strait Islander Health, fund culturally appropriate birthing services, either in hospitals or stand alone, in centres with large Aboriginal and Torres Strait Islander populations.

While endorsing the recommendation to provide culturally appropriate birthing services to Indigenous women, the OATSIH notes that it does not have a role in provision of tertiary care services. Tertiary care services are the responsibility of State and Territory Governments. Local hospitals and/or stand alone clinics should be encouraged to work together with Aboriginal Community Controlled Health Organisations to ensure the provision of culturally safe and appropriate services for Aboriginal and Torres Strait Islander women. Such collaboration is essential for continuum of care and to give a greater focus to the health needs of Aboriginal and Torres Strait Islander women in mainstream health programs.

Decisions relating to the allocation of AHCA funding to public hospitals for particular purposes, including culturally appropriate birthing services, rest with State and Territory Governments.

CHAPTER 5: INTERVENTIONS IN CHILDBIRTH – CAESAREAN SECTION

Recommendation 23:

The Committee recommends that the National Health and Medical Research Council work with the relevant professional bodies to develop best practice guidelines for elective Caesarean sections.

The NHMRC has had an ongoing interest in antenatal care, and in 1996 published the paper Options for effective childbirth that explored the then predominantly medically-based model of childbirth procedures, and offered other options without compromising the desire of consumers for safety. Subsequent to the release of the paper, the need for clear information for consumers on elective caesarean sections was identified, and the NHMRC is currently working with key organisations to prepare appropriate literature.

Recommendation 24:

The Committee recommends that the Commonwealth Government work with State Governments to decide a target rate for Caesarean sections, moving towards the target of 15% recommended by the World Health Organisation.

As the Committee Report notes, the rates for Caesarean sections vary greatly between countries. The Government believes that the key issue is to ensure adoption of best practice guidelines for elective Caesarean sections and to ensure women have appropriate information available to them. Setting targets does not necessarily address these issues although it may point to issues of differential practice that the profession may then address. Establishment of targets also raises the issue of what happens when that figure is reached or and women who want, or need, a procedure, cannot be given it.

Under the AHCAs, State and Territory Governments are responsible for ensuring the provision of public hospital services, including admitted and non-admitted patient services, free of charge to public patients on the basis of clinical need and within a clinically appropriate period. Against this background, the AHCAs do not afford the Commonwealth the authority to raise issues with State and Territory Governments regarding the target rate for Caesarean sections in relation to public hospital services.

Recommendation 25:

The Committee recommends that the Joint Maternity Services Committee monitor the implementation of best practice guidelines for Caesarean sections and report upon the extent to which individual hospitals meet the proposed target for Caesarean sections of 15%.

As the Report notes, membership of the Joint Committee on Maternity Services includes representatives from the Royal Australian College of Obstetricians and Gynaecologists and the Australian College of Midwives Incorporated. The Committee is largely inactive at present. Any broader role for this Committee would need to be taken up by the Colleges involved.

See also the response to recommendation 24 above.

Once best practice guidelines have been established, caesarean services could be restructured in the Medicare Benefits Schedule to reflect those guidelines. Where the guidelines recommend clinical indications for caesarean, individual caesarean items could be introduced for each of these clinical indications. Caesareans for non-clinical reasons or clinical situations not recommended under the guidelines could be excluded from the Medicare Benefits Schedule.

Privately insured patients have a higher rate of caesarean sections, as previous ly noted. This restructure could provide aggregate data on the clinical reasons for which private patients are undergoing caesarean. It would also assist in ensuring that Medicare benefits for caesarean sections are only paid for caesarean services provided within the best practice guidelines.CHAPTER 7: BEST PRACTICE GUIDELINES FOR ANTENATAL CARE AND FOR CARE DURING BIRTH

Recommendation 26:

The Committee recommends that research and guidelines on the use of routine ultrasound in pregnancy be an immediate priority for the National Health and Medical Research Council. An earlier recommendation set out those aspects of routine ultrasound requiring urgent attention.

The National Health and Medical Research Council (NHMRC) is the Commonwealth Government’s principal vehicle for funding medical research. As a general rule the NHMRC does not dictate what research will be undertaken. The NHMRC directs the majority of funds on the basis of scientific excellence in research to projects initiated by the research community itself.

• While most research is investigator-initiated, the Strategic Research Development Committee (SRDC) of NHMRC is charged with identifying and filling gaps in the national research effort. The SRDC has recently completed consultative workshops around Australia to inform the setting of the SRDC research agenda. Peak organisations are asked to nominate issues they believe are important, addressing specific criteria which include measures of the burden of the disease and whether the issue is of particular relevance to Australia.

The Senate Committee’s recommendation has been referred to the NHMRC for further consideration.

Recommendation 27:

The Committee recommends the enhancement of the Joint Committee on Maternity Services to include professional groups involved in antenatal, birth and post natal care as well as consumers. The Joint Committee should have responsibility for advising Ministers on the implementation and evaluation of best practice guidelines in maternal and infant health care and on measures to reduce current fragmentation in the provision of maternal and infant health services.

See response to recommendation 25 above.

Recommendation 28:

The Committee recommends that the Commonwealth Government work with State Governments to ensure the annual publication of a list of all of its hospitals where births take place, with statistics on each of the birth-related interventions performed there and the insurance status of the women on whom they are performed.

The Australian Institute of Health and Welfare (AIHW) is an independent health and welfare statistics and information agency within the portfolio of Health and Aged Care. AIHW has responsibility, in collaboration with the Australian Bureau of Statistics for the development, collection and publication of national health and welfare statistics. AIHW considers that a national report could be produced containing information on birth related interventions, if appropriate funding was available.

However, for confidentiality reasons such a report would not be able to include information identified at the establishment level. Also the AIHW would have concerns regarding the quality of ‘insurance status’ as reported in the national hospital data, and would recommend further validation of this data item prior to any analysis being undertaken.

CHAPTER 8: POST NATAL CARE

Recommendation 29:

The Committee recommends that the Commonwealth Government work with State Governments to ensure that maternity and infant welfare services are in place to assist women following their return home after childbirth.

State and Territory Governments have responsibility for the provision of maternity and infant welfare services. The Government, however, recognises the importance of postnatal care. An increasing amount of evidence is available to support the premise that the early months and years of life set the scene for health and well being throughout life. In particular, there is evidence that the diet of a child has an important impact on health in latter years.

The Government recently announced funding of $15 millio n over three years for a childhood nutrition program to be implemented within the framework of the National Population Nutrition Strategy and complementing the National Breastfeeding Strategy. Work within the Commonwealth Department of Family and Community Services relates to improving support for young families through programs like the Good Beginnings national parenting project.

In addition, funding provided to Divisions of General Practice through the National Divisions Hospital Integration Program and the other Practice Incentives Program have led to considerable innovation and integration of postnatal services.

For better integration of hospital and community care, consideration could be given to introducing into the Medicare Benefits Schedule enhanced primary care type items for postnatal care for the mother and baby. These items could be based on the same principle as those recently introduced for the elderly and those with multidisciplinary problems; they provide for assessment of the care needs and the co-ordination of that care between the doctor and allied health care professionals.

There may be some savings in terms of re-admission for such things as feeding difficulties, treatment for infections, mastitis, post natal depression (for which some studies suggest a link with early discharge and lack of support) and other related conditions.

Recommendation 30:

The Committee recommends that community care services for women discharged early from hospital following childbirth be eligible for funding through the National Demonstration Hospitals Program.

See response to recommendation 29 above.

It would not be appropriate to provide funding for support services for women discharged early from hospital f ollowing childbirth through the National Demonstration Hospitals Program (NDHP), because the NDHP is a time limited program designed to foster innovation in the provision of hospital services.

The NDHP does not fund additional service provision, rather it provides temporary additional funds for hospitals to explore and develop new approaches to the organisation and delivery of services that can be implemented and sustained without the need for additional funds beyond the time of their involvement in the program.

There have been three phases to the NDHP, the first two of which are complete. The third and last phase of the program is currently underway. The focus of the first phase was improvements in elective surgery management for public patients. The focus of the second was improvements in integration in the management of all kinds of hospital admissions, discharges and transfers. The third phase is focussing on integration between hospital and non-hospital services.

Although there has not been a specific focus on maternity services within the NDHP, given that NDHP projects are designed to act as catalysts for organisation-wide improvements in the quality and effectiveness of service delivery, it is reasonable to assume that midwifery patients accessing these hospitals have benefited from initiatives funded by the program.

Of the projects funded by the NDHP in major tertiary teaching hospitals over two thirds have taken place in hospitals with a substantial component of midwifery patients. Similarly, of the 60 other hospitals that have participated in the program over three quarters provide care for midwifery patie nts.

Recommendation 31:

The Committee recommends that the National Health and Medical Research Council conduct research into post natal depression.

As discussed in the response to recommendation 26, while most research is investigator initiated, the Strategic Research Development Committee (SRDC) of NHMRC is charged with identifying and filling gaps in the national research effort. The Committee’s recommendation for research has been referred to the NHMRC for further consideration in that context.

The National Health and Medical Research Council (NHMRC) has, however produced information for clinicians and consumers on postnatal depression.

In 1998 the NHMRC was commissioned by the Department of Health and Aged Care to develop information on postnatal depression that would assist clinicians to detect and treat the disorder. The NHMRC completed the project in November 1999 and endorsed the publication Postnatal depression: a systematic review of published scientific literature

1980-1999. The paper presents a review of current literature that may be useful for practitioners and consumers to understand the condition, and inform clinical management decisions.

CHAPTER 9: FUNDING ISSUES

Recommendation 32:

The Committee recommends that the Health Insurance Commission monitor the new Medicare rebate for complex births to ensure that it does not lead to overservicing.

The Department is monitoring the use of this item on an ongoing basis using Health Insurance Commission data. Monitoring is based on the appropriateness of item use as well as the identification of possible overservicing. The Department is working with the Health Insurance Commission in this regard.

Recommendation 33:

The Committee recommends that the Health Insurance Act be amended to define as ‘patients’ all neonates in hospital who require medical attention, regardless of whether they are located with their mothers or not.

The Government considers that there is no logic in admitting to a hospital, well persons (in this case well newborn babies), as they do not require the acute and intense medical and nursing care provided in a hospital setting. This arrangement has been well-established for many years and is accepted by all State and Territory health authorities and the health insurance and private hospital industries, as is evidenced by the definition of 'admitted patient' contained in the National Health Data Dictionary (Version 9, 2000,

pp. 265-257).

As the Committee noted, where a neonate requires care which is available in a location separate from its mother in accordance with agreed standards for neonatal care facilities, then the neonate is considered to be an admitted patient. The Department of Health and Aged Care consults regularly with the Division of Paediatrics, Royal Australasian College of Physicians, regarding standards for the treatment of neonates. The College recently reviewed these standards and indicated to the Department that they remain current.

However, given recent advances in technology and treatments for seriously ill newborns, the Department has also requested the College to review whether babies with certain serious conditions might be safely accommodated and treated next to the mother's bedside rather than in an approved special care nursery. Their advice will inform possible future developments in the standards for the treatment of neonates.

The Government considers that this recommendation would have little effect on the administration of the Medicare Benefits Schedule and would seem to be more of an eligibility issue.

CHAPTER 10: LITIGATION AND OBSTETRIC PRACTICE AND PROVISION

Recommendation 34:

The Committee recommends that the Australian Institute of Health and Welfare establish national comprehensive data on medical defence organisations to cover negligence cases and include such data as premium payments, number of cases, number of claims, number of out of court settlements, size of payments and size of fund reserves.

The Australian Institute of Health and Welfare advises that to undertake such a collection would require the support of indemnity insurers and substantial additional resources. The Government does not agree that this recommendation is a priority or that there is sound evidence to support funds being allocated to this at this point in time.

Recommendation 35:

The Committee recommends that the Commonwealth Government establish an independent inquiry into medical indemnity and litigation, including the impact of litigation and indemnity on the provision and practice of obstetric services, alternative approaches to the funding of medical litigation and alternative approaches to the funding of compensation for disability.

The Government does not believe that an independent inquiry into medical indemnity is appropriate at this point in time. These matters will be best handled through the current consultative process between the Department of Health and Aged Care and the profession.

As an example, following the Australian Medical Association’s proposal of a Cerebral Palsy compensation scheme at their summit of 10 December 1999, the Department of Health and Aged Care has met with the profession in relation to the medical indemnity issue and will continue to do so in order to properly pursue these issues.

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