Collaborative arrangements: changes ahead?

On 10th August, the Standing Council on Health agreed to change the Collaborative Arrangements Determination.  The Determination currently requires a midwife to have a collaborative arrangement with an individual doctor, of a specified kind, in order for the midwife's client to claim a Medicare benefit for care provided by the midwife.  This would be fine if obstetricians and GP Obstetricians were willing to collaborate with midwives on a large scale.  The reality has been that most obstetricians and GP obstetricians have been unwilling to collaborate with private midwives, and this had led to women being unable to claim Medicare benefits for private midwifery care. The Determination will now be amended to allow midwives to collaborate with health services and hospitals, rather than individual obstetricians.  This is seen by many as being a very positive step forward.

Perhaps I'm cynical.  I can't see how this is any more positive than the current arrangements.

Currently, hospitals are unwilling to collaborate with private midwives.  Despite almost two years since the reforms came into being, there is only one hospital in the whole of Australia that has been willing to facilitate admitting rights for private midwives.  The various States are individually working on policies to enable admitting rights for private midwives, but this process has been slow to reach fruition.  In the meantime, some hospitals (a handful) are allowing midwives to become antenatal shared care providers and a handful are offering midwives to become employees for the delivery of inpatient birth care to women.

Given hospitals' overall reluctance to collaborate with private midwives on a large scale thus far, I'm not confident that this proposed change to the Determination will improve a midwife's ability to provide Medicare-funded care on a large scale.  In any case, the changes necessary to facilitate hospital-private midwife collaboration are similar to the processes that are needed to facilitate admitting rights.  Why not simply take the opportunity to effect midwife admitting rights?

I am further skeptical that the changes will result in any great change because the same individual obstetricians who have refused to collaborate with private midwives are the same obstetricians who are employed in our public hospitals.  If they are declining to collaborate in a private arrangement, what makes us confident they will collaborate within the public system?

Finally, the "public/private" dilemma is not resolved.  Private midwives are not insured to provide care to public patients.  When a woman sees her private midwife for care, she is a private patient, in the same way that she is a private patient if she sees a private obstetrician.  Private midwives have insurance to care for private patients.  However, when a woman goes into a public hospital and receives care from obstetric staff who are employed by the hospital, the woman is a public patient.  Whilst the midwife can attend the consultation with the woman, if she uses her midwifery knowledge or skills in any way, she may be deemed to be practicing midwifery without insurance.  This is in breach of our registration standards.  I believe it is impossible not to use knowledge and skills.  The purpose of an obstetric consult / referral / transfer is to enlist obstetric care when a woman's / baby's condition lies outside the scope of midwifery care.  This would then require a written care plan that is agreed by the woman, midwife and doctor.  This is in accordance with our Guidelines for practice and our insurance policies.   How does a midwife participate in the drafting of this care plan with the woman and the doctor, if she cannot use her knowledge and skills in preparing it?  I think it's impossible!  If anyone knows the answer, please let me know!

So, for many reasons, I don't believe that the new changes to the Determination will have any significant impact without some major policy change to support:

  1. A midwife's attendance at an obstetric consult / transfer in the capacity of a midwife rather than as a support person (current stipulation)
  2. The ability of a hospital-employed obstetrician to collaborate with a private midwife
  3. Hospitals' willingness to work with private midwives
  4. Midwife admitting rights

Doctors, meanwhile, are very strongly opposed to this change to the Collaborative Arrangements Determination, stating that it undermines collaborative care arrangements and risks patient safety.

“The collaborative care arrangements were carefully devised and agreed with the relevant health professional groups in the best interests of patient safety and team-based coordinated care."

They are concerned that midwives might practice more "independently" as a result of the changes to the Determination.

Apparently,

"When the collaborative care arrangements were being developed, it was agreed that the midwife could have an agreement with a doctor in a hospital, who would ensure appropriate care arrangements were in place."

Doctors were consulted every step of the way with the maternity reforms.  Collaborative care arrangements were developed with much input from obstetricians.  Unfortunately, obstetricians have declined to collaborate with private midwives and across Australia, there are only a few collaborative agreements that have been signed between private midwives and private obstetricians.  I currently provide all of my care to women within a collaborative agreement with a private obstetrician in a model that delivers excellent care and safety to women and babies while maintaining continuity and choice for women from early pregnancy, through to birth and the postnatal period.  However, it is the only model I know of in the whole country!

In 2011, NASOG (National Association of Specialist Obstetricians and Gynaecologists) commenced a survey of obstetricians on the issue of midwife collaboration, stating,

"Media reports have claimed that obstetricians have refused collaboration with midwives. We want to test this claim with a short survey of NASOG members."

The study seems to be ongoing, judging by the link actively taking the reader to the survey.  I can only conclude that the results of this survey - commenced in 2011 - have either yielded negative responses, or too few responses to publish.  Perhaps those media reports were correct after all.

If more obstetricians had agreed to work with midwives, there would be no need to relax the requirements for collaboration because on a large scale, women would be benefiting from continuity of midwifery care, funded by Medicare, within a collaborative model involving obstetricians.

We have learned that midwives are working collaboratively - actively approaching obstetricians for collaboration and referring women appropriately.  I'm sad and disappointed that these changes to the Determination have become necessary.  Obstetricians' refusal to collaborate is leading to more fractured and fragmented care through the public system, where women will not benefit from continuity of obstetric care while also deriving the benefits of continuity of midwifery care.  This is a loss for Australian women.

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