Improving maternity services for Indigenous women in Australia: moving from policy to practice

The disparities in health outcomes between Aboriginal and Torres Strait Islander (hereafter called Indigenous) and non-Indigenous Australians are well established, with the life expectancy gap being among the worst in the world.1 There is growing evidence that the chronic diseases that are prevalent in Indigenous Australian adults (diabetes, hypertension, cardiovascular and renal disease) have their genesis in utero and in early life.2,3 One of the greatest medical threats to the wellbeing of Indigenous children is being born preterm or at a low birthweight (LBW). Australian Indigenous babies are almost twice as likely to be born LBW than Australian non-Indigenous babies or Indigenous babies from similar countries (Box). Other contributors to poor outcomes include the enduring effects of colonisation, social exclusion, sustained institutionalised racism, and stark inequities across many of the social determinants of health, including income, employment, education, and access to goods, services and health care.6,7

Australia’s National Maternity Services Plan (NMSP) states that Australia is “one of the safest countries in the world in which to give birth or to be born. However, this is not the case for Aboriginal and Torres Strait Islander people.”8 The NMSP was based on an extensive review of maternity services.9 It set out a 5-year vision for the years 2010–2015, and a framework for implementation with the federal, state and territory governments endorsing the plan and committing to long term improvements, investments and service developments under four key areas: access, service delivery, workforce and infrastructure. Actions for the initial, middle and later years were identified, as were indicators to measure the signs of success. The NMSP identified three priority areas for Indigenous women: (i) increasing the Indigenous workforce; (ii) increasing culturally competent maternity care; and (iii) developing dedicated programs for Birthing on Country.8

We reviewed government documents that are freely available and related to the NMSP, including annual reports.10–12 We included relevant literature published since the release of the Review of Maternity Services in 2009,9 and other literature related to maternity services for Indigenous women. We examined the four key areas in relation to the priority areas for Indigenous women. We note that the NMSP did result in additional benefits to all Australian women that are not detailed in our review, for example the development of the National Evidence-Based Antenatal Care Guidelines.

Priority 1: The Indigenous maternity workforce

Action 3.2 of the NMSP was to develop and support an Indigenous maternity workforce across all disciplines and qualifications, and to provide more scholarships (such as the Puggy Hunter Memorial Scheme) to facilitate this action. Small one-off initiatives are seeing slow progress in this area with some jurisdictions doing better than others. In 2015, there were 230 Indigenous midwives nationally, comprising only 1% of the midwife population, while Indigenous Australians constitute 3% of the population and 6% of all Australian births.13 Additionally there is a marked drop-out of midwifery graduates from clinical roles soon after graduation, and this highlights a need for ongoing support.14

Across Australia, we are seeing an increasing number of maternity models that recognise the contribution of Indigenous workers who have a variety of titles and job descriptions. Some recognise the importance and cultural expertise of elders and grandmothers like the Strong Women Workers,15 while others aim to provide women support through bicultural partnerships between midwives and maternal infant health workers,14–19 with some supporting Indigenous student midwives (Appendix). This is a positive start that needs dedicated funding for scaling up and monitoring. In Canada, the Inuit have managed this in very remote settings,20 but we see little of this in Australia. Increasing the Indigenous workforce is likely to increase the cultural competence of the whole workforce and the workplace.14

Priority 2: Culturally competent maternity care

Action 2.2 of the NMSP was to develop and expand culturally competent maternity care for Indigenous Australians. Cultural competency is best comprehended as a philosophy and paradigm for transformational heath practice. Importantly, the ideologies with cultural competence, safety, security and respect are to embed knowledge, skills and values to create change to enable culturally responsive and informed care. Evidence from America has shown that the use of this approach in government-funded agencies has improved the knowledge and attitudes of health professionals working with clients from marginalised groups, whose disparities are costing health services greatly.21 The NMSP tackled this by commissioning a literature review to document the characteristics of culturally competent maternity care and draft indicators for measurement.22 Further work was to develop mechanisms for evaluating cultural competence in maternity care and undertake a national stocktake of access to culturally competent maternity care; both have yet to be completed. However, the establishment of the National Centre for Cultural Competence, a joint venture of the Australian Government and the University of Sydney, is likely to have an impact nationally with online and workshop cultural competency training and resources available for a broad audience. Additionally, the Congress of Aboriginal and Torres Strait Islander Nurses and Midwives provide face-to-face health-specific training in cultural safety.

Cultural competency education and training is a strategy aimed at addressing health disparities, although further development and work are required to appreciate the most effective methods, the flow-on effect of training to patients, and the best tools for measuring cultural competence in individuals, organisations and in the maternity setting.21–23 Critically, “racism constitutes a ‘double burden’ for Indigenous Australians, encumbering their health as well as access to effective and timely health care services.”24 Achieving culturally competent maternity services is key to improving maternity care and good health for mothers and babies.25

Another emerging area in developing a cultural competent workforce is that of trauma-informed care and practice, whereby care providers understand the ongoing impact of intergenerational trauma resulting from historical injustices, colonisation, removal from and dispossession of land, and continuing racism.26 This is particularly important given that Indigenous children are overrepresented in out-of-home care compared with non-Indigenous children (nine times higher; 35%27), with some women encountering the child protection system during pregnancy, leading to the removal of their babies at birth. This is an incredibly distressing situation for all involved, but most particularly the mother. Redirecting funding from removal to supporting vulnerable families would see greater short and long term benefits.

Although maternity services in Australia are designed to offer women the best care, they largely reflect modern western medical values and perceptions of health, risk and safety.28 This is unlike the Indigenous world view, reflected in their definition of health, which incorporates not just physical wellbeing, but also the social, emotional and cultural wellbeing of individuals and the whole community.7

Maternity systems have failed to incorporate the evidence provided by Indigenous women on the impact of social risks that include cultural risk (eg, the belief that not being born on their land threatens claims to land rights) and emotional risks (having to spend weeks removed from family and other children while awaiting birth).29,30 Recent empirical work in Australia reconfirms that these risks are still valid, highlighting that they not only cause distress to women and families, but also increase clinical and medical risks (eg, women not attending antenatal care, or presenting late in labour, to avoid being flown out of their community for birth); this is a factor not well understood by health service leaders.28 The risks are greater for Indigenous women from remote and very remote communities, some of whom feel that giving birth in hospitals, many miles from their home, may be the cause of ill health as it breaks the link between strong culture, strong health and the land, a link that is strengthened during birth.31 While away from community and other children awaiting the birth, pregnant women are susceptible to anxiety, stress and depression, and often have particular concerns that their other children may be vulnerable to child protection services in their absence.30

We acknowledge the importance of clinical and medical risk, but suggest that the definition of risk needs be broader, to incorporate the social (cultural, emotional and spiritual) risks as valid and important dimensions of risk assessment requiring risk management processes. For example, when women need to leave their community for specialist care, strategies to ensure her other children are safe, or can travel with her, must be implemented as part of the risk management process. The disconnection between social, cultural and spiritual risk and western clinical and medical biophysical risk is a critical and understudied phenomenon that needs further work.

Priority 3: Dedicated programs for “Birthing on Country”

Action 1.4 of the NMSP was to increase access to high quality maternity care for women and their family members in remote Australia. Twenty-four per cent of Indigenous women who give birth each year live in remote and very remote Australia (versus 2% of non-Indigenous women), highlighting the importance of services in these areas. Although there has been some improvement in pregnancy care in some communities,32 empirical studies continue to report the challenges of providing maternity services in these areas, a lack of regular access to midwifery care and suboptimal quality of care caused by the lack of a systematic approach, appropriate clinical governance and cultural competence among health care providers.18,33,34 One approach to solving this in some of the larger remote and very remote communities is to establish Birthing on Country sites.

Action 2.2.3 of the Plan addressed Birthing on Country, which was defined as maternity services designed and delivered for Indigenous women that encompassed some or all of the following elements:

were community based or governed;
incorporated traditional practice;
recognised the connection with land and country;
incorporated a holistic definition of health;
valued both Indigenous and non-Indigenous ways of knowing, learning and risk assessment; and;
were culturally competent and developed by, or with, Indigenous people.35

The Maternity Services Inter-Jurisdictional Committee brokered a literature review of Birthing on Country programs in Australia, New Zealand, Canada and America to determine if any had made a significant improvement to outcomes. The review found a number of programs met the criteria, but there was a dearth of high quality research, with most studies having short term evaluations, small numbers and potential selection bias. Despite this, some programs show significant improvements in antenatal attendance, screening and treatment; immunisation rates; mean birth weight; reduced preterm birth and cost; and women report increased satisfaction (see full report35 for details, and the Appendix to this article for examples).

The Inuit model in Northern Quebec provided the most robust evidence of an “exemplar model”, where three Birthing on Country services operate in places that are many hours by plane from facilities where caesarean delivery can be performed. These facilities meet community expectations, address clinical/medical, social/cultural, spiritual and emotional risks and have improved maternal and infant health outcomes while supporting local midwifery training.20 Increasing numbers of these services are operating in Canada, with some having been sustainable since the mid-1980s and early 1990s.20 The benefits of community-based birthing services, over and above the improvements in maternal infant health outcomes, include community healing, comprehensive tailored care, support of the community, local training and employment and reduced family separation at critical times.20 The evidence suggested that a Birthing on Country model of maternity care would most likely produce significantly improved outcomes for Indigenous women in very remote through to urban areas.35

The review was followed by a national Birthing on Country workshop, facilitated by the Maternity Services Inter-Jurisdictional Committee and Congress Alukura in Alice Springs in 2012. Participants voiced concern that “Birthing on Country”, as a term, lacked clarity which may have contributed to a lack of engagement from key service providers and government departments. Nevertheless, participants proposed that Birthing on Country be retained and understood as “a metaphor for the best start in life for Aboriginal and Torres Strait Islander babies and their families, an appropriate transition to motherhood and parenting for women, and an integrated, holistic and culturally appropriate model of care.”36 The middle and later years of the NMSP were to see Birthing on Country programs developed and evaluated, with the workshop recommending that “exemplar sites” be established in urban, rural, remote and very remote areas to deliver “… not only bio-physical outcomes … it’s much, much broader than just the labour and delivery … [Birthing on Country] deals with socio-cultural and spiritual risk that is not dealt with in the current systems”36

Birthing on Country in remote and very remote Australia

Despite policy frameworks that support primary maternity services delivering culturally competent care closer to home,7,8,37 demand from Indigenous women and communities,38,39 and multiple recommendations over 25 years,8,38–41 there has been no progress towards establishing and evaluating Birthing on Country services in remote or very remote Australia. In these areas, such services would need to be Primary Maternity Units or Services, which are defined in the National Maternity Services Capability Framework42 (Action 4.2.2 of the Plan saw the development of this Framework) as Level 2 services. Internationally, there is strong empirical evidence that Primary Maternity Units/Services provide safe perinatal care for women classified as being at low risk of complications,43,44 including in rural and remote areas.20,45 Despite this, few such services operate in Australia (3 urban/regional; 17 rural; 0 remote),46 reflecting a centralisation of services, a lack of medical support in some cases, safety and sustainability concerns in others.44,47 In fact, Australia has seen a 41% decline in maternity services over the 20 years from 1992 to 2011, especially in rural areas, correlating with a 47% increase in unplanned out-of-hospital births (22 814 births).48 There is an unequivocal relationship between distance to maternity services and poorer clinical49 and psychosocial outcomes.50,51 This lends support to the argument to prioritise Birthing on Country models in remote and very remote areas, where some of the most disadvantaged women in Australia live the furthest from maternity services.

Determining the appropriate level of maternity services that are safe and will be sustainable in a given location is challenging. Action 4.2.1 in the NMSP was to develop rigorous methods to help with planning maternity care in rural and remote communities. This work was completed with the development of the Australian Rural Birth Index, which can be used to determine the appropriate level of maternity service for a community, based on the average number of births in a community, the vulnerability of the community, and distance to a facility that can perform caesarean delivery.52 The work accompanying this project found disparities in access to services across Australia and minimal adjustment for the needs of vulnerable, rural and remote populations. Additionally, the project identified that the perceived risks to health services of operating services in remote areas is given priority over the clinical and social risks experienced by families (when they do not have local maternity services).28

Where to from here?

The Review of Maternity Services outlined serious challenges that needed attention in Australia and recognised a clear role for leadership by the Australian Government in concert with state and territory governments.9 The NMSP was developed to address these issues and to measure progress.8 There is little doubt that it resulted in the strengthening of maternity services in some areas. Additionally, three National Health and Medical Research Council Partnership projects are advancing Birthing on Country in urban areas. In Perth, there is a project exploring the Cultural Security of Aboriginal Birthing Women;53 in Melbourne, the Aboriginal Community Controlled Health Organisations (ACCHOs) and three large hospitals are offering all Indigenous women one-on-one midwifery care with a known midwife antenatally, in labour and up to 6 weeks postnatally;54 and, in Brisbane, one of us (S K) is working with two ACCHOs and two large maternity hospitals to develop and evaluate an Urban Birthing on Country service model. Several jurisdictions are developing models incorporating some of the principles of Birthing on Country; most are successfully engaging pregnant women earlier and more often than standard care, and early evaluations are starting to show improved outcomes (Appendix).

We must not lose this momentum. It is time for a new maternity services plan with high level monitoring to continue to tackle emerging priorities and complete unfinished business, particularly for Indigenous women in rural and remote communities. Three professional organisations (the Australian College of Midwives, the Congress of Aboriginal and Torres Strait Islander Nurses and Midwives and the Remote Health Organisation, CRANAplus) have released a position statement calling for action,55 and recommending the Australian government show leadership and develop a strategic approach to implementing and evaluating Birthing on Country programs. We believe that leadership in this area must continue to come from the Australian government, with greater urgency than has been evident to date. Dedicated funding must be allocated towards supporting the Indigenous maternity workforce, developing and measuring culturally competent care and establishing Birthing on Country sites in urban, rural and particularly in remote and very remote communities. This recommendation is based on international evidence that already exists, and government funding should extend to generating further evidence so the lessons learned can be applied to sites elsewhere.

Box –
International comparison of rates of low birthweight

Source: Australian Health Ministers’ Advisory Council4 and Australian Institute of Health and Welfare.5

Models of maternity care: evidence for midwifery continuity of care

In Australia, 300 000 women give birth each year, with almost all using maternity care services, either public or private.1 Maternity services are the third most common specialised service offered by hospitals,2,3 accounting for more than one million patient-days annually.4 The most common principal diagnosis for overnight hospital stays is single spontaneous birth, which accounts for 4.2% of acute separations in public hospitals and 2.4% in private hospitals.4

The provision of high quality maternal and newborn care is an important global aim, as articulated by the United Nations.5 In Australia, the 2011 National Maternity Services Plan stated that “All Australian women will have access to high-quality, evidence-based, culturally competent maternity care in a range of settings close to where they live” and recognised that continuity of care is very important for women.6 This plan followed the Maternity Services Review, which made recommendations regarding access to a range of models of maternity care, with a focus on women in rural and remote areas and Aboriginal and Torres Strait Islander women, and the need to build and support the maternity workforce to ensure the provision of safe, quality care for all women.7

Much has happened in Australia and globally over the past decade in the provision of maternal and child health services, and specifically regarding models of maternity care. Here, my aim was to review the current evidence for models of maternity care that provide midwifery continuity of care, in terms of their impact on clinical outcomes, the views of midwives and childbearing women, and health service costs. I used PubMed to identify original studies and review articles for the past 15 years (2001 onwards), as well as national policy reports and guidelines, to formulate an evidence-based overview of midwifery models of care and their application in the maternity care system. The key search terms included midwife, midwifery continuity of care, continuity of carer, midwife-led and midwifery services. I also searched the reference lists of identified articles for further studies.

What are models of maternity care?

To review the evidence for midwifery models of care, an understanding of how such models are defined is first needed. “Models of maternity care” is a term frequently used but poorly understood. An extensive literature review undertaken by the Australian Institute of Health and Welfare found that models of care in general are poorly defined.8,9 One definition of a model of care is “an overarching design for the provision of a particular type of health care service that is shaped by a theoretic basis, EBP [evidence-based practice] and defined standards”.10

Models of maternity care can be provided in both the private and public sectors by obstetricians, general practitioners and midwives. In Australia, the Maternity Services Review defined maternity services as essentially falling within one of four broad models of care: private maternity care, combined maternity care, public hospital care and shared maternity care.6 However, there are many more nuances in the way maternity models of care are configured, depending on the sector (public or private), the risk status of the pregnant woman (low risk, high risk, or mixed), the carer (midwife, doctor, Aboriginal health worker), the way care is organised (caseload, collaborative links), the location (hospital, community, home) and the way women move through the model from entry to exit.8 To deal with these complexities, a national project has been developing a classification system for models of maternity care.11,12 This project has identified the major categories of models of care, including midwifery models of care that provide continuity of care (Box). Midwife-led continuity of care models include midwifery group practice caseload care, team midwifery care and private midwifery care. Midwifery group practice caseload care and team midwifery care are the focus of this review.

Midwifery continuity of care models: the evidence for benefit

In the past two decades, considerable research has been undertaken into models of maternity care that provide midwifery continuity of care. A Cochrane review of midwife-led continuity of care models included 15 randomised controlled trials involving 17 674 mothers and their babies.13 Seven of these trials were undertaken in Australia: in New South Wales,14–17 Victoria18,19 and Queensland.15,20 All 15 trials included women receiving care from licensed professional midwives, in collaboration with doctors where necessary. In most trials, the women were predominantly at low risk of obstetric complications, although in one of the more recent trials, conducted in Sydney and Brisbane, women were of a mixed obstetric and medical risk status and were not transferred out of the model if they developed further risk factors.15 Trials that included homebirth were excluded. A possible limitation of this Cochrane review is that it examined both team midwifery and caseload models, as it is not yet clear which model is most effective.

The findings showed benefits and no adverse effects compared with other models of care.13 Women who received midwife-led continuity of care were more likely to have a midwife they knew with them during labour and birth, more likely to have a spontaneous vaginal birth and less likely to have epidural analgesia, episiotomies or instrumental births. Women were less likely to experience a pre-term birth, and their babies were at a lower risk of dying (including all deaths before and after 24 weeks’ gestation and neonatal deaths). Women rated midwife-led continuity of care models highly in terms of satisfaction and there was a trend towards a cost-saving effect for the midwife-led models, although there was inconsistency in reporting of both these outcomes.13 The review concluded that “most women should be offered midwife-led continuity models of care”. While some trials included women of mixed risk who were cared for in collaboration with doctors, more research is needed to determine the most effective models of care for women with existing serious pregnancy or health complications. In addition, the included trials were all from high income countries, making generalisations to the context of low to middle income countries difficult.

The Cochrane review of midwife-led continuity of care models was one of the reviews analysed to develop a framework for quality maternal and newborn care for The Lancet’s Midwifery Series.21,22 The framework emphasised the centrality of midwifery continuity of carer in providing the care that is needed by women and newborn infants, regardless of setting, and highlighted the importance of working collaboratively in interdisciplinary teams to provide care for women and infants who have, or develop, complications.23

Midwifery continuity of carer has also been examined in non-randomised studies, although these carry an inherently increased risk of bias. These include a study in a large referral centre in Sydney, where a third of pregnant women received care through a midwifery continuity of care (caseload care) model.24 Midwives were organised in groups of four and were responsible for the care of a specified caseload of women throughout pregnancy, birth and the post partum period.25 The midwives followed the Australian College of Midwives’ National midwifery guidelines for consultation and referral.26 In this study, a “standard primipara”, defined as a first time, “low-risk” mother, was used as the unit of comparison, to reduce differences between the caseload care, standard hospital care and private obstetric care groups. Women who received caseload care were more likely to have a spontaneous onset of labour and an unassisted vaginal birth and less likely to have an elective caesarean delivery than those in the other two groups, with lower average costs of care.24

Midwifery continuity of carer can also be provided in “free-standing midwifery units”. In these units, primary level care is provided by a named midwife, with no routine involvement of medical staff. The units are geographically separate from the referral centres that provide obstetric, paediatric or specialised medical consultations when necessary. Free-standing midwifery units do not provide epidural analgesia or caesarean deliveries on site. A prospective cohort study of two such units in NSW showed that women who planned to give birth at a free-standing midwifery unit were more likely to have a spontaneous vaginal birth, less likely to have a caesarean delivery and had no differences in 5 minute Apgar scores compared with women who planned to give birth in tertiary level maternity units.27 Babies from the freestanding midwifery unit group were significantly less likely to be admitted to neonatal intensive care or the special care nursery. However, only two such units exist in Australia, suggesting that widespread implementation would be a challenge. Although this study analysed where mothers intended to give birth rather than where they actually did give birth, this accurately reflects the need for transfer in some women, and analysing according to intention is important in studies on place of birth. There was some crossover between the groups in actual birth locations, but these involved only 1% of the study population.

Across Australia, similar clinical and cost outcomes have been reported from non-randomised studies of midwifery continuity of carer in South Australia,28 Queensland29 and NSW.30 A review of 22 international non-randomised studies has also shown that low risk women in midwife-led, birth centre or homebirth services in the care of midwives experienced fewer obstetric interventions and were more likely to have a normal birth without complications than low risk women receiving standard hospital or obstetric care.31 Although these were non-randomised studies, with diverse study designs and models of care, they nevertheless provide additional evidence supporting midwifery continuity of care.

Midwifery models of care for specific groups

Midwifery models of care have been implemented for a range of specific groups, especially young women and women from minority or marginalised groups. For example, a retrospective cohort study in Queensland showed that women younger than 21 years of age who were allocated to midwifery continuity of carer (caseload care) were less likely to have a pre-term birth or to have their baby admitted to a neonatal intensive care unit than those receiving standard care.32

In Australia, Aboriginal and Torres Strait Islander women and babies experience higher maternal and perinatal morbidity and mortality rates than their non-Indigenous counterparts.1 Several models that provide midwifery continuity of carer have been specifically designed and evaluated for Aboriginal and Torres Strait Islander women.

In the Northern Territory, two such midwifery models have been evaluated. A midwifery group practice in Alice Springs catered for 763 local women, 40% of whom were Aboriginal, over 4 years. This model of care has eight midwives who work in pairs or teams of three, depending on skill level and work hours. Each pregnant woman is assigned a primary midwife, with back-up from her primary midwife’s colleagues, who she meets during her pregnancy. A retrospective review found that the rates of perinatal mortality, pre-term birth and low birthweight babies for these women were lower than those reported for the NT population.33 Retrospective analysis such as this has inherent limitations due to the nature of the data and the ability to make comparisons; however, a randomised controlled trial would not have been feasible or possible in this setting.

The other study in the NT involved a new model of maternity care for remote-dwelling Aboriginal women, who were transferred to a regional centre in Darwin to await birth. Women were provided with midwifery continuity of care from their arrival in Darwin until their transfer back home, with effective communication networks between the regional centre and remote community health centres. The study showed that, for the first time, Aboriginal women could access continuity of care once they reached Darwin, and the women reported more positive experiences with maternity services than previously.34 The model was shown to be cost-effective for remote-dwelling Aboriginal women of all risk levels.35

In a more urban setting, a midwifery continuity of carer model was established in an area of high socio-economic disadvantage in Sydney, to meet the needs of Aboriginal women and families, as well as non-Aboriginal women and families from nearby suburbs, many of whom were from migrant and refugee communities.36 The service was based in a suburban house 6 km from the referral hospital. Women received antenatal care and postnatal or child health services from the house and gave birth in the labour ward of the referral hospital. The service was staffed by midwives, Aboriginal health education officers, a community health worker and a child and family health nurse. The midwives and Aboriginal health education officers accompanied the women to the hospital if they needed to attend for antenatal visits, and the midwives were on call to care for the women when they went into labour. An evaluation of qualitative and quantitative data showed that women and the local community valued the service and that women were likely to attend for antenatal care early in pregnancy and to engage with health promotion initiatives, such as smoking cessation.36 Continuity of caregiver (midwife and Aboriginal health education officer) was highlighted, with women in the focus groups speaking of this aspect as being “the best part” of the service.

Midwifery continuity of care: effect on organisations and midwives

In both the public and private sectors, midwifery continuity of care is usually provided in a caseload model. These midwives work on call rather than on a shift-based roster and usually have arranged times for antenatal and postnatal care (provided either in hospital or community settings or women’s homes). The midwives usually work in partnerships or small groups to enable care by a back-up midwife who is known to the woman, should her primary midwife be unavailable.37,38 They also work within hospital guidelines and collaborate with non-caseload midwives, managers, obstetricians and other medical specialists as required. In Australia, a full-time caseload midwife in a public hospital model cares for 30–40 women per year as the primary midwife (depending on the complexity of the women’s pregnancies) and provides back-up for colleagues who usually have a similar caseload.39 Industrial guidelines, which vary across the country, ensure that midwives have adequate time off and are fairly remunerated for their on-call work.

Some midwifery continuity of carer models are based in birth centres, while others use the hospital’s standard labour ward. There are a few models that also provide access to publicly funded homebirth for carefully screened women at low risk of complications.40,41

Midwifery continuity of carer, or caseload midwifery, has been associated with positive outcomes for midwives. Research from Victoria showed that caseload midwives had lower burnout scores and higher professional satisfaction than midwives who worked in standard shift-based ways.42 This was a small study from one setting, but similar findings have also been reported from Adelaide,43 the United Kingdom44 and New Zealand.45 In a recent qualitative study in Australia, newly graduated midwives who were supported, mentored and orientated reported considerable benefits from working in midwifery continuity of care models and were highly satisfied with their work.46,47

Translating this evidence into practice

Currently in Australia, although midwifery continuity of care and carer is espoused in many state48 and national6 policy documents, with “toolkits”49,50 and guidance39 also available, widespread implementation remains limited. A recent national survey aimed to determine the prevalence of and factors associated with implementation and sustainability of midwifery models of care, especially caseload midwifery services.51 Participants were the maternity managers of the 235 public hospitals that provide birthing services. The survey had a 63% response rate (149/235), representing all states and territories; metropolitan, regional and remote areas; and hospitals with very small to very large birth numbers. Only 31% of responders reported that their hospital offered caseload midwifery, with an estimated 8% of women receiving caseload care at that time. Of those hospitals without a caseload model, 62% reported that they were planning to establish one. The survey showed that midwifery continuity of care models were expanding across the country and that there was strong perceived consumer interest in such models. Most hospitals with a caseload model reported having more women who wanted to access this model than there were places available, and community demand was high in areas where implementation was being considered.51 The findings of this study are clearly limited by its response rate of 63%, and further research examining the models of midwifery care available in Australia is needed to quantify the translation of evidence into practice.

Despite this survey’s limitations, it is clear that midwifery continuity of carer is not being widely implemented in Australia. Factors contributing to this include a lack of midwifery and medical leadership, workforce shortages and fears about the autonomy of midwives. A lack of medical staff support continues to be cited as an obstacle to change in many services.51 Nevertheless, some services have been developed through effective and respectful collaboration between midwives and doctors, and there is evidence that such interprofessional collaboration is attainable in midwifery continuity of care models.52

Recruiting and retaining midwives who are interested in and available for work in this model remain problems for many services. However, all new graduates from Australian midwifery programs have had opportunities to work in this way during their education,53 and many want to work this way in the future.54 Midwifery continuity of care is a “different” way of working, and it takes time for midwives and their managers to adapt to working on call, with fewer boundaries between work and personal time.38 This is not always embraced by service managers, medical staff or hospitals, as it requires trusting the midwives and enabling them to develop professional relationships with women and to assume responsibility, accountability, autonomy and legitimacy in their practice.38

Many hospital managers raise concerns about the effects of staff burnout on the sustainability of midwifery continuity of care models.55 Despite this, research in the UK has shown that high levels of occupational autonomy and assistance with ensuring a work–life balance provide a protective effect on the levels of burnout for midwives.56

Models of midwifery care for the future

Globally, the understanding that midwifery models of care are best practice for all pregnant women is gathering momentum. The evidence is now clear; there is Level I evidence from well conducted randomised controlled trials showing benefit for women and the health system, and numerous non-randomised studies show similar benefits for women, midwives and organisations. Recent international policy documents highlight the need for midwifery continuity of carer. For example, the 5-year forward view for maternity care in England, known as “Better Births”, recommends:57

Continuity of carer, to ensure safe care based on a relationship of mutual trust and respect in line with the woman’s decisions. Every woman should have a midwife, who is part of a small team of 4 to 6 midwives, based in the community who knows the woman and family, and can provide continuity throughout the pregnancy, birth and postnatally.

The Australian maternity care system is similar to that in the UK, and this recommendation was based on evidence partly drawn from Australian studies.13

To bridge the gap in translating the evidence into clinical practice in Australia, widespread reorganisation of the way maternity services are provided is required. Midwifery continuity of carer programs can no longer be implemented as pilot programs or in piecemeal ways for small numbers of women; the evidence and the demand are now so strong that widespread reform is needed. A critical part of such reform is effective collaboration with obstetricians, general practitioners, paediatricians and other medical professionals involved in the care of pregnant women. Enabling and facilitating midwives to take a lead role in the care of women is an essential step in the process of reforming the maternity care system. A better understanding of the barriers and challenges associated with implementing midwifery continuity of care is also needed, and further research should examine this research–practice gap.

Despite the need for more research into ways to effectively implement this model of care in practice, is it ethical to withhold access to midwifery continuity of care from the majority of women in Australia, given the strength of evidence, the supporting policy documents and the demand from women? Future models of maternity care in Australia need to ensure that women have access to midwifery continuity of care. Midwives need to be valued and respected in their roles as key providers of primary maternity services in all settings for childbearing women in Australia. Flexible ways of working need to be enabled so that midwives can provide continuity of care, and innovative funding models in the public and private sectors need to be developed so that women can access the maternity care provider they need and want.

Box –
Identified major categories of models of maternity care in Australia11

Model of care category

Description

Midwifery group practice (public) caseload care

Antenatal, intrapartum and postnatal care is provided by a known primary midwife with a secondary back-up midwife or midwives providing cover, and with assistance from doctors where needed.* Antenatal and postnatal care is provided in the hospital, community or home, with intrapartum care in a hospital, birth centre or home.

Team midwifery care

Antenatal, intrapartum and postnatal care is provided by a small team of rostered midwives, in collaboration with doctors where needed.* Intrapartum care is usually provided in a hospital or birth centre. Postnatal care may continue in the home or community, provided by the team midwives.

Private midwifery care

Antenatal, intrapartum and postnatal care is provided by a private midwife or group of midwives, in collaboration with doctors where needed.* Intrapartum and postnatal care is provided in a range of locations, including at home.

Shared care

Antenatal care is provided by a community provider (doctor and/or midwife) in collaboration with hospital staff under an established agreement. Intrapartum and early postnatal care is usually provided in the hospital by hospital midwives and doctors, often in conjunction with the community provider (particularly in rural settings).

Combined care

Antenatal care is provided by a private maternity service provider (doctor and/or midwife) in the community. Intrapartum and early postnatal care is provided in the public hospital by hospital midwives and doctors. Postnatal care may continue in the home or community, provided by hospital midwives.

Private obstetrician (specialist) care

Antenatal care is provided by a private specialist obstetrician. Intrapartum care is provided in a private or public hospital by the private specialist obstetrician and hospital midwives. Postnatal care is provided in hospital and may continue in the home or a hotel.

Private obstetrician and privately practising midwife joint care

Antenatal, intrapartum and postnatal care is provided by a privately practising obstetrician and midwife from the same private practice. Intrapartum care is provided in either a private or public hospital by the privately practising obstetrician, midwife and/or hospital midwives. Postnatal care is provided in hospital and may continue in the home, hotel or hostel, provided by the private midwife.

General practitioner obstetrician care

Antenatal care is provided by a GP obstetrician. Intrapartum care is provided in a private or public hospital by the GP obstetrician and hospital midwives. Postnatal care is provided in the hospital by the GP obstetrician and hospital midwives and may continue in the home or community.

Public hospital maternity care

Antenatal care is provided in hospital outpatient clinics (onsite or outreach) by midwives and/or doctors. Intrapartum and postnatal care is provided in the hospital by midwives and doctors. Postnatal care may continue in the home or community, provided by hospital midwives.

Public hospital high risk maternity care

Antenatal care is provided to women with medical high risk or complex pregnancies by maternity care providers with an interest in high risk maternity care (specialist obstetricians or maternal–fetal medicine subspecialists with midwives) in a public hospital. Intrapartum and postnatal care is provided by hospital doctors and midwives. Postnatal care may continue in the home or community, provided by hospital midwives.

Remote area maternity care

Antenatal and postnatal care is provided in remote communities by a remote area midwife (or a remote area nurse) or group of midwives, sometimes in collaboration with a remote area nurse and/or doctor, with telehealth or fly-in–fly-out clinicians. Intrapartum and postnatal care is provided in a regional or metropolitan hospital (involving temporary relocation before labour) by hospital midwives and doctors.

* Collaboration with doctors “where needed” means “in the event of identified risk factors”.

[Articles] Global, regional, and national levels of maternal mortality, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015

Several challenges to improving reproductive health lie ahead in the SDG era. Countries should establish or renew systems for collection and timely dissemination of health data; expand coverage and improve quality of family planning services, including access to contraception and safe abortion to address high adolescent fertility; invest in improving health system capacity, including coverage of routine reproductive health care and of more advanced obstetric care—including EmOC; adapt health systems and data collection systems to monitor and reverse the increase in indirect, other direct, and late maternal deaths, especially in high SDI locations; and examine their own performance with respect to their SDI level, using that information to formulate strategies to improve performance and ensure optimum reproductive health of their population.

Ley refuses to set rebate freeze end date

Health Minister Sussan Ley has dumped on hopes of an imminent end to the Medicare rebate freeze, warning that it will not be lifted until there is an improvement in the Federal Government’s finances.

Talking down the prospects of financial relief for hard-pressed medical practices any time soon, Ms Ley refused to set a date for an end to the policy, and told ABC radio’s AM program that “we cannot lift the pause…any earlier than our financial circumstances permit”.

The Minister said any decisions made about the freeze would be made in the context of Budget discussions.

“I’m a Minister who signs up to the agenda of a Government that leads Budget repair and strong, stable economic management, so I’m absolutely not walking from our responsibilities,” she told Sky News. “These are decisions that are made through the MYEFO [Mid-Year Economic and Fiscal Outlook] and Budget process, and I’m not going to forecast when or what they might be.”

The Government is due to release the 2016-17 MYEFO before the end of the year, most likely early December.

Ms Ley backed away from comments she made during the Federal election that she had been blocked from ending the freeze by her senior Treasury and Finance colleagues.

In May, Ms Ley told ABC radio that: “I’ve said to doctors I want that freeze lifted as soon as possible but I appreciate that Finance and Treasury aren’t allowing me to do it just yet.”

But when ABC reporter Kim Landers said to the Minister today that, “you’ve previously said that you’ve wanted to lift it, but you were blocked by Treasury,” Ms Ley denied it.

“That’s not what I’ve said. What I’ve said is: as a responsible Minister in a Government that needs to undertake budget repair, I recognise that we cannot lift the pause that was introduced by Labor any earlier than our financial circumstances permit,” the Health Minister said.

The exchange came amid mounting warnings from the AMA and others that the rebate freeze is pushing medical practices to the financial brink, forcing many to abandon bulk billing and raising the prospect that patients will be charged up to $25 in out-of-pocket costs.

Ms Ley defended the rebate freeze as the right policy for the times, and said bulk billing rates had “never been higher”.

The Minister’s declaration, which is based on figures measuring the number of Medicare services performed rather than GP consults, has been disputed by those who claim that the real figure is closer to 69 per cent.

Regardless, AMA President Dr Michael Gannon expressed disbelief the rebate freeze would still be in place by the time of the next election in late 2019.

“I would be gobsmacked if the Government took an ongoing freeze to the next election,” the AMA President said following a meeting with Ms Ley earlier this year. “They got the scare of their life on health, and that was probably the policy which hurt them the most.”

Ms Ley said that she wanted the freeze to end “as soon as possible”, but refused to nominate an end date.

“I’m sure that others in the Cabinet and the Parliament want that day to be as soon as possible,” the Minister said. “But we also recognise our responsibilities in terms of our credit rating, in terms of the national debt, in terms of, as I said, the economic circumstances that Labor left us with.”

Adrian Rollins

Mental health services—in brief 2016

Mental health services—In brief 2016 provides an overview of data about the national response of the health and welfare system to the mental health care needs of Australians. It is designed to accompany the more comprehensive data on Australia’s mental health services available online at .

Government pathology changes could cost practices up to $150m

Federal Government plans to change the rules regarding rents for pathology collection centres could be a disaster for medical practices, ripping up to $150 million a year from their income, the AMA has warned.

AMA President Dr Michael Gannon has told Health Minister Sussan Ley that a significant number of general practices will become “collateral damage” if the Government persists with plans to change the definition of ‘market value’ that applies to rents for pathology collection centres, with serious consequences for the provision of health care.

Dr Gannon said the Minister needed to re-think the proposed changes and adopt a more nuanced approach “consistent with the original intent of the…laws”.

“If you do not get this right, a significant proportion of general practices will become collateral damage, which would be a disastrous policy outcome and contrary to your stated support for the specialty,” he told Ms Ley.

Last month it was revealed that the Government had put off plans to axe bulk billing incentives for pathology services and abandoned its threat to impose a moratorium on the development of new collection centres.

In a climb-down, the Government pulled back from its threat to scrap the incentives on 1 October and advised it would not be proceeding with the moratorium, which was announced during the Federal election in order to head off a protest campaign by the pathology industry against the axing of a bulk billing incentive.

Instead of a ban, the Government has directed that collection centre leases be put up for renewal every six months, down from the usual 12 months, until a new regulatory framework is put in place. Existing leases will be grandfathered for up to 12 months, after which the new rules will come into effect.

The bulk billing incentive cut, meanwhile, which was originally due to come into effect from 1 July and save $332 million, will now not be implemented until 1 January 2017.

“Bulk billing incentives for the pathology sector will continue until new regulatory arrangements are put in place and the Government will continue to consult with affected stakeholders,” a spokesman for Ms Ley told the Herald Sun.

But the Minister is persisting with plans to change the regulations governing rents for approved collection centres, particularly regarding the definition of market value as applied under the prohibited practices provisions of the Health Insurance Act.

Dr Gannon said that in talks earlier this year, the AMA had agreed with moves to strengthen compliance with existing regulations and “weed out examples of rents that are clearly inappropriate”.

But he said the Government at that stage had given no hint it was considering changes to the regulations, and its election announcement had taken all stakeholders, except Pathology Australia and Sonic Healthcare, by surprise.

Dr Gannon said the Government’s clear intent was to control collection centre rents, and the AMA opposed the proposed changes.

There are more than 5000 collection centres across the country, many co-located with medical practices.

“These practices are small businesses and have negotiated leases in good faith,” Dr Gannon said, and had made business decisions based on projected rental revenue streams, including staffing and investment.

He warned that ripping this source of revenue away could be disastrous for many.

“For many practices feeling the impact of the current MBS indexation freeze, this source of rental income has helped keep them viable,” he said, adding that AMA estimates were that the Government’s changes would cost practices between $100 million and $150 million a year in lost rent revenue.

“The magnitude of this cut goes well beyond an attempt to tackle inappropriate rental arrangements. It is causing significant distress, particularly for general practice,” Dr Gannon said. “I doubt the Government truly contemplated the extent of the impact of its election commitment when it was announced.”

Latest news

Modest health bill growth belies ‘unsustainable’ claims

Federal Government complaints about unsustainable growth in health spending have been undermined by figures showing its health bill is growing little faster than the pace of inflation.

Australian Institute of Health and Welfare figures show Commonwealth health spending increased by 2.4 per cent to $66.2 billion in 2014-15, compared with a 2.3 per cent rise in underlying inflation over the same period.

State and Territory government spending was even weaker, contracting by 0.4 per cent to $42 billion – the first such decline in a decade.

The results undermine the Government’s case for swingeing cuts in the health budget, which have been based on assertions that public spending on hospitals, GPs and other health services has been out of control.

The AIHW’s Health expenditure Australian 2014-15 report shows, instead, that Federal Government spending has slowed sharply in recent years. 2014-15 was the third year in a row where expenditure growth was below the annual average of 4 per cent.

The figures demonstrate that increasingly the burden of health funding is falling onto the shoulders of patients, either directly through rising out-of-pocket costs or indirectly via rising private health insurance premiums.

Between 2004-05 and 2014-15, the Commonwealth’s share of the nation’s health bill slipped from 43.9 to 41 per cent. Over the same period, the states’ and territories’ share increased from 24 to 26 per cent, for individuals it went from 17.4 to 17.7 per cent and for health funds, from 7.7 to 8.7 per cent.

The cost-shifting was particularly stark in the three years to 2014-15, when a 1.3 percentage point jump in the health insurer’s share coincided with a 2 percentage point plunge in the Federal Government’s share.

The AIHW said this was driven by changes in the Government’s private health insurance rebates that had the effect of cutting its contribution, with insurers (and, more particularly, policyholders) picking up the tab. The development casts attempts to blame the surge in premiums on doctor fees or procedure costs in a different light.

Partly the shift in the Federal Government’s share can be explained by changes in revenue. The Commonwealth’s tax take has been hammered by the global financial crisis and the wind-down of the mining boom, and shrank by 1.5 per cent in 2014-15. By contrast, State and Territory tax collections have been growing at an above-average pace for the past decade. This has meant that while health has been grabbing a greater share of tax revenue at the Federal Government level, at the State and Territory level it has been shrinking.

Overall, the nation’s spending on health increased by 2.8 per cent in 2014-15 to $161.6 billion – well down from the 10-year average growth rate of 4.6 per cent.

However, because of the slowdown in the broader economy, health expenditure as a proportion of GDP actually increased 0.2 of a percentage point to reach 10 per cent of total output for the first time.

This is higher than the developed country median of around 9.1 per cent, but is comparable with countries including New Zealand, Canada, the United Kingdom and Finland, and far below the United States, where health expenditure accounts for 16.6 per cent of GDP.

Per person, Australia spends $6657 on health – ranked 10^th highest among OECD countries but well below the US ($13,266), Switzerland ($9977) and Norway ($8940).

Adrian Rollins

Hospital trial turns night into day for US doctors, patients

Picture: Dr Timothy Buchman talks to a colleague in Atlanta from the ‘Turning Night Into Day’ centre at Macquarie University

Night has become day for a group of US doctors and critical care nurses, who are using new technology to remotely monitor their intensive care patients in hospitals in Atlanta from a Sydney health campus.

The intensivists and nurses from US health provider Emory Healthcare are part of a clinical trial to assess the health benefits for both patients and doctors of having highly experienced clinicians available to provide senior support around the clock.

Taking advantage of remote intensive care unit (eICU) technology and the 14-hour time difference, the medical teams are essentially working the Atlanta night shift during the day in Sydney.

“We’re in Australia because we are trying to look at a different model of care,” Cheryl Hiddleson, the director of Emory’s eICU Centre, told Australian Medicine.

“We were having our clinicians up all night while they were trying to do other things during the day – that’s just what happens. We know that working the night shift is tough.

“This study is to look at our staff and see how the difference in the times that they are working makes to their performance and their health.”

Under the trial, senior intensivists and critical care nurses from Emory are based in Sydney for six to eight week rotations.

They work at MQ Health at Macquarie University, using eICU technology developed by health technology maker Royal Philips, to provide continuous night-time critical care oversight to high-risk patients in Emory’s six hospitals across the state of Georgia.

“We intensive care folk have one mission, and that’s to deliver the right care for the right patients at the right time,” Dr Timothy Buchman, the chief of Emory’s Critical Care Services, said.

“Almost everything we do has to be done with both speed and care. That’s easy in a big hospital at 10am on a Monday, but that task becomes a lot harder in a remote or rural hospital at unsocial hours – on weekends, holiday, or especially at night.

“There are fewer people, and less experienced people, and patients can become sicker around the clock. Patients and their families deserve the best care, and this is about bringing that senior support to the bedside.”

The day before Dr Buchman spoke to Australian Medicine, he helped treat a patient who had been airlifted to one of Emory’s Atlanta hospitals at 2am US time – 4pm in Sydney.

The patient was suffering severe pancreatitis and respiratory failure, and was being treated by a relatively junior doctor.

“I had a complete echo of the bedside monitor, and was able to guide the doctor through the treatment,” Dr Buchman said.

“The attending physician would have been at home, probably asleep. But I was able to go in as if I was there and help implement care plans.”

Two hours later, another patient came in from a smaller hospital, suffering post-operative haemorrhaging.

“She was deeply anaemic, but she was also a Jehovah’s Witness and so was refusing blood products,” Dr Buchman said.

“The other hospital said we needed experimental therapies, so we accepted her admission. I was able to evaluate her remotely and provide the level of care she needed. When I came in to work this morning, I was able to check on her condition again.”

The previous night, just before 1am, the family of a terminally ill cancer patient, who had been intubated earlier in the day, requested a meeting to evaluate his care.

“I was able to talk to them – they could see me, I could see them – and they decided to shift from aggressive care to comfort,” Dr Buchman said.

“The patient was able to die. His family were able to be there and it was able to occur in a timely fashion. The family had come to a decision and acceptance, and they could have that meeting when they needed it, instead of having to wait for hours.”

Emory already uses the eICU to provide senior support to smaller and remote hospitals throughout Georgia. The time difference trial is intended to see if the technology can help keep senior clinicians in the workforce.

“People do function a lot better when they can do night work in day time,” Dr Buchman said.

“This technology is important, but it is only an enabler. The people – the staff, the patients – are what is important, and this technology gives us the ability to use this accumulated wisdom during daylight for patients on the other side of the world who would not normally have access to this level of expertise.”

Maria Hawthorne

Device reforms may be too late to prevent premium pain

The Federal Government is coming under pressure to speed up its review of prosthetic prices if consumers are to avoid another painful hike in private health insurance premiums.

Health funds have warned that unless the cost of medical devices on the Prostheses List falls into line with the much lower prices paid by public hospital in the next few weeks, policyholders will continue to pay an extra $150 to $300 on their premiums.

The warning is the latest shot in a tussle underway between insurers, medical device manufacturers and private hospitals other over the cost of prostheses, as documented in a series of articles in The Australian newspaper.

The health funds, increasingly worried about the backlash from consumers over rapidly rising premiums and complex and confusing insurance products, have set their sights on prostheses prices as a key way to contain costs.

They claim that existing pricing arrangements are woefully out of date and force insurers to pay grossly inflated prices for medical devices compared with public hospitals. According to insurers, they are being charged up to $3450 for a coronary stent that costs $1200 in the public system, while a defibrillator costing them $52,000 costs a WA public hospital just $22,555.

Altogether, the funds estimate they could save $800 million by bringing public and private prostheses prices into line, savings they say would be passed on in cheaper premiums for consumers.

But the Medical Technology Association of Australia, which represents medical device manufacturers, has defended the sector against what it considers to be false and misleading claims.

MTAA co-lead Andrea Kunca said the industry rejected accusations of inflated pricing and fully supported the work of a Government working group brought together earlier this year to work through “meaningful solutions” for reform of the Prostheses List.

The Australian has published claims that the MTAA, in concert with private hospital operators, has so far been successful in frustrating attempts by Health Minster Sussan Ley to reform the Prostheses List, and any changes are unlikely to come in time to head off another sharp increase in the health fund premiums next year.

According to The Australian, fierce lobbying by well-connected outfit CapitalHill Advisory on behalf of the MTAA derailed an early attempt by Ms Ley to cut implant prices.

Influential Senator Nick Xenophon has announced he will push for a Senate inquiry into private health insurance and the pricing of medical devices on the Prostheses List, a move welcomed by the MTAA.

“There have been a number of misleading and false claims put in the public arena in regards to the medical device industry,” Ms Kunca said. “A Senate inquiry will allow these false claims to be answered once and for all. From the MTAA’s perspective we look forward to presenting the facts rather than anecdotal misinformation put forward by some.”

Premium crunch time

The health funds have to submit proposals for their 2017 premiums, which have to be approved by the Health Minister and are announced in April, by early November.

Doctors, insurers and the Government fret that another 6.5 per cent premium increase could accelerate the shift among policyholders toward cheaper policies with multiple exclusions and less coverage, or even convince many to ditch private health cover altogether – the insurance industry has cited research that at least 20 per cent of current members would find premiums unaffordable in the next six years.

Ms Ley recently overhauled the membership of the Prostheses Listing Advisory Committee, appointing University of New South Wales Professor of Medicine Terry Campbell as Chair. Professor Campbell’s appointment was a belated replacement of long-serving Chair Professor John Horvath, who left last December to become a strategic adviser at Ramsay Health Care.

The stoush comes against the backdrop of rising dissatisfaction among doctors and consumers with the quality and value for money of private health insurance.

The AMA has been a vocal critic of the proliferation of complex and confusing policies, many with multiple exclusions that leave unsuspecting patients with inadequate cover.

AMA President Dr Michael Gannon has declared the medical profession’s support for Government reforms to improve the value of private health insurance by banning junk public hospital-only policies, standardising terms, mandating minimum levels of cover and preserving community rating.

Dr Gannon said doctors were doing the right thing, with 86 per cent of privately insured medical services charged on a no gap basis, and a further 6.4 per cent involving a known gap.

“This means that less than 8 per cent of privately insured patients are charged fees that exceed that paid by their private health insurance,” the AMA President told the National Press Club in August. “Put simply, the majority of doctors and hospitals understand the impact of gaps on patients and are doing the right thing by them.”

He said that because of these, doctors were deeply unimpressed with the behaviour of some insurers, “particularly the biggest and most profitable ones”, in putting profits ahead of the interests of patients.

Dr Gannon said that if such actions, including aggressive negotiations with private hospitals and attacks on the professionalism of doctors, continued unchecked “we will inevitably see US-style managed care arrangements in place in Australia”.

Adrian Rollins

Govt adviser calls for public hospitals to be ‘contestable’

Mortality rates and treatment outcomes for individual hospitals and medical practitioners could be made publicly available and patients given a choice of hospital and specialist under Productivity Commission proposals to improve the quality and accessibility of health services.

In the preliminary findings of a review initiated by Treasurer Scott Morrison into options for increased competition and consumer choice in the $300 billion human services sector, the Commission has proposed increased information disclosure by hospitals and practitioners and greater contestability between services.

“Greater competition, contestability and informed user choice could improve outcomes in many human services,” the PC said. “Well-designed reform, underpinned by strong government stewardship, could improve the quality of services, increase access…and help people have a greater say over the services they use and who provides them.”

Mr Morrison said he had ordered the review to improve the efficiency and cost effectiveness of human services.

But Opposition leader Bill Shorten, reprising Labor’s scare campaign during the Federal election on the privatisation of Medicare, said he feared it would be used to justify the wholesale handover of human services to the private sector.

“We’ve all seen this move before,” Mr Shorten said. “When Malcolm Turnbull and the Liberal Party start talking about changing human services it means that poor people get it in the neck.”

The Commission said that not all human services were amenable to increased competition, contestability and choice, but identified public hospitals and palliative care services among six priority areas targeted for reform.

While Australian public hospitals performed well by international standards, “there is scope to improve”, the PC said, including by matching domestic best practice and publicly disclosing more information.

“Public patients are often given little or no choice over who treats them or where. Overseas experience indicates that, when hospital patients are able to plan services in advance and access useful information to compare providers (doctors and hospitals), user choice can lead to improved service quality and efficiency,” the PC said.

It said that any reforms to boost user choice would have to be supported by “user-oriented information”, and suggested the English model in which increased choice is offered at the point where GPs refer patients to a specialist.

The Commission said experience in England had shown that patients given a choice of hospital and consultant-led team sought out better performing providers, and hospitals in locations where competition was most intense recorded the biggest improvements in service quality.

In order to exercise their choice, patients had access to web-based information enabling them to compare providers according to waiting times and mortality rates, and could use an online booking service.

The enormous variety of Australia’s public hospitals, including big differences in the populations they serve, workforce arrangements and characteristics and the complexity of their links to the rest of the health system, militate against like-for-like competition – something the Commission admitted.

If such issues or political considerations made fostering direct competition unfeasible, the Commission instead suggested exerting pressure for improved performance by making the position of senior hospital managers more precarious.

“There have been difficulties in the past commissioning non-government providers, and lessons from these attempts should not be forgotten,” it said. “As a result, it may be more feasible to implement contestability as a more transparent mechanism to replace an underperforming public hospital’s management team (or board of the local health network) rather than switch to a non-government provider.”

The Commission said State and Territory governments could also take a more contestable approach to commissioning services when renegotiating service agreements with local health networks.

On palliative care, the PC lamented that a dearth of comprehensive, publicly available national data hampered accountability and helped drive big differences in the quality and range of services available.

It said there was little evidence that low quality providers were being held to account.

The PC acknowledged that the “emotionally taxing and psychologically distressing” environment in which a person was approaching the end of their life militated against making choices about palliative care.

“Taboos about discussing death can prevent this from happening,” the Commission said. “Patients often rely on medical professionals to initiate conversations about palliative care, many of whom are inadequately trained about, and intimidated by, holding such conversations.”

Notwithstanding such challenges, the PC argued that introducing greater competition, contestability and user choice in palliative care would improve outcomes and reduce current substantial variation in the quality of, and access to, services in different areas of the country.

To achieve this, though, “would require careful design to ensure that the interests of patients and their families are well served. Special measures for consumer protection may be needed”.

Indeed, even where reform ushered in greater competition and contestability, the PC said the unique nature of human services meant the Government would need to maintain strong oversight.

“Government stewardship is critical,” the agency said. “This includes ensuring human services meet standards of quality, suitability and accessibility, giving people the support they need to make choices, ensuring the appropriate consumer safeguards are in place, and encouraging and adopting ongoing improvements to service provision.”

Other priority areas of human services nominated by the Commission for increased competition and contestability included public dental services, social housing, services in remote Indigenous communities and grant-based family and community services.

Among those areas assessed for reform but not identified as a priority by the PC at this stage were general practice, primary health networks (PHNs), mental health services, community health services and child and family health services.

The preliminary report is open for submissions until 27 October, and the Commission is due to deliver its final report by October 2017.

Adrian Rollins