Competence to practise: an unmistakable
fact or a holy grail?
…
Professor Mary Chiarella
Wednesday 11th February 2015
SYDNEY NURSING SCHOOL
Outline
› Professionalism and professional regulation
› Elements of professional regulation
› The question of competence assurance or continuing competence.
› The regulation of midwifery –a whistlestop tour
Definition of a profession
› “An occupation whose core element is work based upon the mastery of a
complex body of knowledge and skills. It is a vocation in which knowledge
of some department of science or learning or the practice of an art
founded upon it is used in the service of others. Its members are governed
by codes of ethics and profess a commitment to competence, integrity and
morality, altruism, and the promotion of the public good within their
domain. These commitments form the basis of a social contract between a
profession and society, which in return grants the profession a monopoly
over the use of its knowledge base, the right to considerable autonomy in
practice and the privilege of self-regulation. Professions and their
members are accountable to those served and to society”(Cruess,
Johnston & Cruess, 2004, p.74).
›
3
The regulation of health professionals
› Forms part of a branch of law known as administrative law
› Is described as a “protective jurisdiction”
› ICN & WHO agree that “The purpose of professional self-regulation is to
safeguard and champion patient safety” (ICN/WHO, 2005 p.7)
› Primary objective of the national registration and accreditation scheme in
Australia under Health Practitioner Regulation National Law 2009 (Qld) Part
One, s.3(2)(a)
- “to provide for the protection of the public by ensuring that only health
practitioners who are suitably trained and qualified to practise in a
competent and ethical manner are registered"
› In most countries this is achieved by a combination of processes:
› 1. Standard setting to ensure the right people get into the profession –this
includes standards for courses (accreditation) and standards for entry
(registration)
› 2. Advice and guidance to assist practitioners to practise “in a competent and
ethical manner”
› 3. Mechanisms to protect the public when they do not practise in a competent
and ethical manner, for whatever reason
4
The “privilege of self-regulation”
› Professional regulation may be taken to read that the
profession regulates itself
› To some extent this is correct, albeit in most countries through
a statutory framework to give “teeth” to the regulatory
processes
› Professions therefore tend to decide
- who should enter the profession,
- what those who enter might look like,
- how they might properly conduct themselves as members of
that profession and
- what criteria would need to be breached in order for them to
be excluded from the profession
5
Professional regulation is not favoured by all
› There is debate as to whether professions should self regulate, set their own
standards and determine who comes in and who leaves ((van Mook et al,
2009; Chief Justice of Ontario Advisory Committee, 2001)
› However, there is also concern that our self regulation can create monopolies
and limit market competition - itself an interesting debate in a service such as
health care (Siebert , 2006)
› "Whereas public regulation was meant to ensure “public protection”, the word
is now increasingly associated with central control, unreasonable bureaucracy
and restraint in international trade and worker mobility.” (ICN, 1998, p.7)
› Given the global migration of nurses today, and the fluctuation between
countries in supply of nurses, both under and over, there is much debate
amongst governments and employers alike about how influential a profession's
hold on regulation ought to be (Ameringer, 2008)
6
Self-regulation or co-regulation?
› Arguably in most countries the model is not one of complete selfregulation, but co-regulation
› Governments already play a significant role in regulation of health
professionals
› Through remuneration systems in both the industrial and commercial
domains
› Through legislation that grants access to the use of therapeutic drugs and
devices
› Through such structures as admitting and visiting rights to hospitals and
other health care facilities; and
› Through processes such as adverse incident reporting and, where serious
adverse events occur, investigations and recommendations from
Commissions of Inquiry.
7
Elements of professional regulation(9) include
› Registration: who should enter the profession and what those who enter
might look like
› Accreditation: oversight of how those who might enter should be
prepared
› Codes and guidelines: how they might properly conduct themselves as
members of that profession;
› and
› Complaints and notifications: what criteria would need to be breached
in order for them to be excluded from the profession
8
The elements of professional regulation (Chiarella
& White, 2013)
•Registration Standards
•Endorsements
•Curriculum standards
•Course guidelines
•Site reviews/inspections
•Competency standards
•Codes of conduct
•Codes of ethics
•Professional guidelines
Registration
Codes and
Guidelines
Accreditation
Complaints
and
notifications
•Performance
•Impairment
•Professional Misconduct
9
Registration – deciding who should enter the
profession
• Registration Standards
• Endorsements
• Codes of conduct
• Codes of ethics
• Professional guidelines
Registration
Codes and
Guidelines
Accreditation
Complaints
and
notifications
• Curriculum standards
• Course guidelines
• Site reviews/inspections
• Performance
• Impairment
• Professional
Misconduct
Registration standards
Deciding who should enter the profession
› Determining (inter alia)
› Age of entry
› Physical and mental well-being
› Fitness to practise
› Prior educational experience
› Educational qualifications (see accreditation also)
› The need for proficiency in the relevant language
› Criminal record checks
› Professional indemnity insurance
› Recency of practice.
11
Domains of RN standards for practice
› Professional Practice
› Critical Thinking and Analysis
› Provision and Coordination of Care
› Collaborative and Therapeutic Practice (NMBA, 2010 –under review)
› Each domain then has a number of elements, and each element has a
number of behavioural cues to assist in assessment.
› In New Zealand nurses undertaking their assessment of continuing
competence are expected to self- assess against the competency
standards (Vernon et al, 2010)
› This use of competency standards is similar to developments in America
and Canada for medicine (WHO, 2005)
12
Codes and Guidelines and Professionalism
• Codes of conduct
• Codes of ethics
•
Professional guidelines
•
Competency
•
standards
• Registration Standards
• Endorsements
• Curriculum standards
• Course guidelines
• Site
reviews/inspections
Registration
Codes and
Guidelines
Accreditation
Complaints
and
notifications
• Performance
• Impairment
• Professional
Misconduct
The provision of professional advice and
standards
› May include
› Sets of competency standards that a health practitioner is required to meet
before entry to the relevant section of a professional register
› Codes of conduct and codes of ethics (the “floors and ceilings” of
professional expectation) (Chiarella, 1995)
› Professional guidelines, that provide assistance and advice to health
professionals on a range of relevant and often difficult matters. (NMBA,
2010)
14
Examples of how to conduct oneself in a
profession
The professional Decision-Making Frameworks (DMF) for nursing and
midwifery (NMBA, 2010)
› The decision-making frameworks assist nurses and midwives
› To identify and work within their relevant and appropriate scopes of
practice
› To make careful and informed decisions about when to delegate work to
another health professional or health care worker with a more confined
scope of practice
› To decide when to take on tasks or assignments that might fall outside
their normal scope of practice.
15
Complaints, notifications and professionalism
• Registration
Standards
• Endorsements
• Curriculum standards
• Course guidelines
• Sire
reviews/inspections
• Codes of conduct
• Codes of ethics
• Professional
guidelines
Registration
Codes and
Guidelines
Accreditation
Complaints
and
notifications
• Performance
• Impairment
• Professional
Misconduct
Managing those who breach the standards set by
the profession
› This may be due to
› A lack of competence in the performance of their professional role
› An impairment issue such as a physical or mental illness disability or an
addiction to drugs or alcohol
› A conduct matter, whereby the individual behaved in such a way as to
incur a determination of unsatisfactory professional conduct or
professional misconduct.
17
Consistent with self /professional regulation?
› Much of the work that is done in terms of assessment and decision making
in relation to complaints and notifications is undertaken by peers.
› The judicial decision making bodies that hear complaints that are
prosecuted are also usually mainly populated by peers (although they
usually have at least one legal and one lay member)
› A number of the changes that have occurred (for example, the introduction
of the HCCC in NSW) came about because the professions did not act
when they needed to do so
› For the public to have faith in us as professionals, they need to be assured
that we will act appropriately when there is the possibility of public risk
› From an educational perspective, there is rich cautionary material within
the professional disciplinary case law (Adrian & Chiarella, 2010)
18
Accreditation and professionalism
•Codes of conduct
•Codes of ethics
•Professional
guidelines
•Registration
Standards
•Endorsements
Registration
Codes and
Guidelines
Accreditation
Complaints
and
notifications
• Curriculum
standards
• Course guidelines
• Site
reviews/inspection
s
•Performance
•Impairment
•Professional
Misconduct
Accreditation
› Only just become a separate body for nursing and midwifery in Australia,
although all other registered health professions had separate accreditation
bodies
› For nursing and midwifery the task was formerly undertaken by the
jurisdictional registration authorities
› However, WHO makes the point that “the legal framework must secure the
autonomy of the accreditation system and ensure the independence of its
quality assessment from government" (p.4). (WHO, 2005)
› The accreditation body sets the standards for the courses and programs
leading to entry to the professions and for post-registration or
specialisation programs where appropriate
› These standards are developed and agreed by the education providers
and key professional stakeholders and in this way, can clearly be seen to
be an arm of professional self-regulation
20
Issues for today’s conversation
› It is recognised that there are significant variations between countries in
the extent and locus of nurse regulation (Benton & Morrison, 2012)
› However, the elements presented above (Chiarella & White, 2013) are
fundamental to any scheme and need to be present to fulfil all criteria for a
professional regulatory process that provides public protection.
› I want to explore continuing professional development and it’s relationship
to competence
› I shall also briefly discuss the regulation of midwifery in Australia
21
Continuing Professional Development (CPD)
› Now an annual mandatory requirement consistent across all registered health
professions in Australia.
› The Medical Board of Australia defines CPD as
› “the means by which members of the profession maintain, improve and
broaden their knowledge, expertise and competence, and develop the
personal qualities required in their professional lives (MBA, 2010)”.
› CPD is a means of ensuring that health professionals keep up to date and
hence are more likely to be safer,
› This relates to the first objective of the national registration and accreditation
scheme in Australia under Part One S.3 (2)(a) of the National Law, which is
› “to provide for the protection of the public by ensuring that only health
practitioners who are suitably trained and qualified to practise in a competent
and ethical manner are registered,
› Health practitioners also believe that CPD is an essential component in
continuing competence (Vernon, Chiarella, Papps & Dignam, 2010)
22
However…
› It is difficult to ascertain how either CPD or indeed recency of practice can
assure competence.
› For example, is there any link between a person who attends a lot of
lectures and a person who is competent?
› Clearly there are people who do complete their requisite CPD but still are
found to be unsafe to practise.
› Indeed it is difficult to be certain that continuing competence can be
assured.
› For example, just because a health practitioner performs competently
during one assessment of competence, they will perform competently the
next time they undertake the same skill.
› I might bake a perfect cake today and burn one tomorrow. Drive my car
well today but have an accident tomorrow.
› Consider the risk matrix below.
23
Risk matrix for the assessment of competence
(Chiarella & White, 2013)
Evidence of sufficient CPD
No evidence of sufficient CPD
competent
Sufficient CPD
Competent
No problem
No CPD
Competent
No problem – they will
be picked up but they
are not dangerous
Not competent
Sufficient CPD
Not competent
Problem – won’t get
picked up as will meet
renewal
requirements
but not safe
No CPD
Not competent
Potential problem but
we should pick them up
through lack of CPD
24
So is continuing competence just a holy grail?
› Perhaps the important aspect of CPD is not necessarily the assurance of
competence, but rather a heightened sense of self-awareness of risk and
the ability to reflect on competence.
› Reviewing our practice against the competency standards or standards for
practice cannot guarantee that we will always be competent. But then
nothing can.
› However, it is perhaps more important that we are aware of our limitations
and strengths and are able to measure these against the requirements of
a given situation.
› Perhaps the more important issue is that we are aware of our level of
competence or incompetence in any given situation.
25
Competence awareness matrix
Aware
Competent
Incompetent
Aware that they are competent
Aware that they are incompetent
*Unaware Unaware that they are competent
Unaware that they are incompetent
26
So….– back to the current study into competence
› Aims
› to explore the interface between professional regulation and competence
to practise, particularly in relation to continuing education and performance
of competence and
› to identify whether public safety can be assured through performance of
competence or awareness of either competence or incompetence.
27
The search for insight
› Insight has been demonstrated to be the deciding factor for adjudicating
bodies in relation to deregistration (Adrian & Chiarella, 2010; Vernon, et
al., 2010; Vernon, 2013).
› Thus the questions that we would like to explore are;
› can insight be identified, measured and assured, and
› is this measurement preferable to the measurement of competence in
clinical performance at a given point of time or in relation to the current
requirements for registration, or renewal of registration / licensure /
certification?
28
Research design
Phase one – Review/audit of CPD and competence notification data
› • Development of CPD review/audit tools
› • Data collection
› • Data collation, thematic and statistical analysis
› Subject data will be elicited from a review / audit of the CPD and recency
profiles of a convenience de-identified sample of registered nurses, drawn
from the data bases of the nursing regulatory boards/councils who
participate in this study. The subject sample will be comprised of
registered nurses from the following two groups:
› Group A. Registered Nurses who have become the subject of competence
notifications based on performance grounds (previous 3 years).
› Group B. Registered Nurses who have been assessed as part of a
recertification / revalidation audit process (previous 3 years).
29
Research design Phase two - Interviews
› • Data collection – interviews
› • Transcription and collation
› • Thematic analysis
› Semi-structured interviews with the ‘performance assessors / competence assessors
commissioned by regulatory authorities, and/or professional organisations to review
performance competence will be undertaken with a view to understanding how
competence is assessed.
› Interview questions will include:
› • What methods of competence assessment are being used?
› • Is there a clear evidence-based assessment policy, process and guidelines?
› • What are the moderation processes?
› • Are there issues that recur in terms of registrants who are required to undertake a
competence assessment i.e. the behavioural traits, history demographics
(awareness/insight?)
› We are also seeking funding to undertake observational studies with theses assessors
30
Research design
Phase three – Analysis of case law (5 years)
› Analysis of five years of case law in each of the selected regulatory
authorities relating to complaints of unsatisfactory performance
(howsoever defined), that have been prosecuted and adjudicated.
› This analysis will be undertaken to identify what factors led to decisions
either to retain or remove a nurse from the register.
› In this case law analysis both the ratio decidendi and the obiter dicta will
be examined for any comment relating to awareness/insight, history,
demographics.
› In addition, relevant country policies and legislation relating to
requirements for competence assurance and CPD will be analysed,
themed and reported.
31
The regulation of midwifery
Midwifery regulation is the set of criteria and processes arising
from the legislation that identifies who is a midwife and who is
not, and describes the scope of midwifery practice.
The scope of practice is those activities which midwives are
educated, competent and authorised to perform.
Registration is the legal right to practise and to use the title of
midwife
ICM “Framework for midwifery legislation and regulation”
32
Background to the development of professional
midwifery in Australia
› First Diploma in Midwifery commenced at the Women’s Hospital in Melbourne in
1888, but only available as a P/G program for RNs
› Midwives Registration Act 1915 (Vic) – made provision for the education and
regulation of midwives
› Nurses and midwives in all jurisdictions were later amalgamated into one
regulatory framework, usually titled a Nurses’ Act
› For many years, it was impossible in Australia to practise midwifery unless you
were also a registered nurse
› First direct entry midwifery program offered in 1997 at Flinders University South
Australia (now 10 available)
› The names of regulatory statutes started changing to Nurses and Midwives Acts
from the mid-90s
› Faculties started rebadging as Nursing and Midwifery faculties
33
Background to the development of professional
midwifery regulation in Australia (cont)
› First Doctor of Midwifery offered from 2000
› First Chief Nurse changed her office title to the Nursing and Midwifery
Office in 2003
› Australian College of Midwives was part of the Australia Peak Nursing and
Midwifery Forum auspiced by then (then) Australian Nursing and Midwifery
Council
› APNMF lobbied hard at the negotiations on the National Registration and
Accreditation Scheme (NRAS) to have a separate midwifery register
› This was achieved and with it the recognition that not all midwives were
nurses
› Still regarded as one profession for the purposes of much of the
organisation of the scheme
34
What does our midwifery workforce look like
› Midwifery in Australia has yet to come of age, although significant strides have
been taken
› Few midwives work in continuity of care models, despite the proven efficacy for
mothers (Tracey et al, 2013)
› Many work in only one aspect of midwifery care –antenatal, labour ward, postnatal,
community, child and family health even
› Australia has dreadful statistics on C-section rates, especially in the private sector,
with some hospitals being as high as 50-60% of all births (WHO recommended
rate is below 15% (WHO, 2010)
35
Our midwifery workforce (cont)
› Such interventionist practices mean that many midwives working in the
private hospital sector do not get the same opportunity to practise
continuity of care or even traditional midwifery
› Yet they identify themselves as midwives and many would espouse
midwifery, woman –centred principles of care
› This unusual situation for our midwifery workforce sees us in a time of
transition as regulators
› We need to be mindful of this when considering CPD and RoP
36
Yet our midwifery workforce is changing
› Continuity of care models are occurring
› Eligible midwife numbers are growing
› Access to MBS and PBS facilitates the move towards improved maternity
care and maternal choice
37
Who advises Health Ministers on midwifery matters?
Lots of people!!!!!!!!!!!
› AHMAC –Australian Health Ministers Advisory Committee (DGs)
› NRAS sub-committee – advises AHMAC – mainly jurisdictional legal reps
but also some workforce – very influential in the early days of the scheme
but completely invisible to the Boards
› AHWPC –Australian Health Workforce Principal Committee
› HPPPC – Health Policy Priorities Principal Committee
› AgManCo –Agency Management Committee of AHPRA (really the Board
of the new NRAS scheme)
› Why does it matter? Because these committees all examine various
aspects of the determinations of the Health Professional Boards – in our
case the Nursing and Midwifery Board of Australia
38
The regulation of midwifery in the new national
regulation scheme
› Two registers, one for nursing, one for midwifery
› Option to be non-practising
› Option to be on either or both
› Registration standards
- Criminal record check
- PII
- CPD
- RoP
- ELS
39
Matters specific to midwifery already contained in the
legislation
› Midwife practitioners
› S.284 exemption for PII for homebirth midwifery
40
Matters specific to midwifery that we addressed after
the legislation was introduced
› Notation for eligible midwives
} these 2
› Endorsement for eligible midwives
}now joined
› The safety and quality guideline (related to S.284)
› All currently under review
41
What is an eligible midwife?
› Not a creation of the national regulatory scheme –provision for registering
midwives and midwife practitioners
› Developed by MSAG during the maternity reforms following the Maternity
Services Review
› MSAG determined that only “eligible midwives” would be eligible for
access to MBS and PBS
› It was agreed that NMBA should take ownership of this as there were
clearly regulatory issues emerging
› MSAG had deemed there had to be a set of criteria for eligibility
› These were being negotiated by other key stakeholders in Canberra
42
So MORE key stakeholders to advise our health
Ministers
› Consumer groups
› Midwifery groups
› Obstetricians and GPs
› Insurers
› Industrial bodies
› PLUS
› All the other people who were already advising them earlier
43
Regulation of eligible midwives
Three NMBA regulatory elements to the registration provisions
› Endorsement as an eligible midwife
› Professional indemnity insurance arrangements in place or midwife meets
the requirements for exemption
› Safety and Quality Guideline for privately practising midwives
› PLUS
› C’th requirements for collaborative arrangements
44
Requirements to be able to provide a Medicare
midwifery service
› To provide a Medicare midwifery service, an eligible midwife is required to
be working in private practice and have:
› A Medicare Provider Number
› Professional indemnity insurance, and
› Collaborative arrangements in place with a specified medical practitioner
and/or credentialed at a hospital or with an entity other than a hospital
(such as a community health centre or a medical practice) that employs or
engages at least one obstetric specified medical practitioner.
45
› Endorsement for scheduled medicines allows a midwife to legally
prescribe medicines in accordance with the respective state and/or
territory drugs and poisons legislation and other associated requirements,
and is gained through meeting the requirements of the Registration
standard for endorsement for scheduled medicines for eligible midwives
developed under the National Law.
46
Endorsement as an eligible midwife
› To be endorsed for scheduled medicines as an eligible midwife, a midwife
must be able to demonstrate, at a minimum, all of the following:
› Current general registration as a midwife in Australia with no conditions on
registration relating to unsatisfactory professional performance or
unprofessional conduct.
› Registration as a midwife constituting the equivalent of 3 years full time /
5000 hours within the past 6 years across the continuum of care or
specified context of practice.
› Successful completion of :
- A Board approved program of study leading to endorsement for scheduled
medicines, or
- A program that is substantially equivalent to such an approved program of study
as determined by the National Board.
47
The PII Exemption under S.284
› The National Law provides an exemption for PII to PPMs providing
intrapartum services in the home providing the following conditions
described in section 284 of the National Law are met:
› (1) During the transition period, a midwife does not contravene section
129(1) merely because the midwife practises private midwifery if—
› (a) the practice occurs in a participating jurisdiction in which, immediately
before the participation day for that jurisdiction, a person was not
prohibited from attending homebirths in the course of practising midwifery
unless professional indemnity insurance arrangements were in place;
and
48
S.284 (1) cont
› b) informed consent has been given by the woman in relation to whom the
midwife is practising private midwifery; and
› (c) the midwife complies with any requirements set out in a code or
guideline approved by the National Board under section 39 about the
practice of private midwifery, including—
› (i) any requirement in a code or guideline about reports to be provided by
midwives practising private midwifery; and
› (ii) any requirement in a code or guideline relating to the safety and quality
of the practice of private midwifery.
49
S.284 (2) & (3)
› (2) A midwife who practises private midwifery under this section is not
required to include in an annual statement under section 109 a declaration
required by subsection (1)(a)(iv) and (v) of that section in relation to the
midwife’s practise of private midwifery during a period of registration that is
within the transition period.
› (3) For the purposes of this section, the transition period—
› (a) starts on 1 July 2010; and
› (b) ends on the prescribed day.
50
Where to from there?
› The Australian Workforce Ministerial Council has extended the transitional
period to end 2015.
› The exemption to PII does not extend to any antenatal and postnatal care
provided by the midwife. PII for antenatal and postnatal care remains the
responsibility of the privately practising midwife and is included in the
approved registration standard for PII.
› A working group under the Health Ministers is currently reviewing what will
happen post 2015
51
Other elements of the SQG
Midwifery competency standards
Scope of Practice
Code of professional conduct for midwives and Code of ethics for midwives
Professional boundaries for midwives
Recency of practice
Continuing professional development
Decision making framework
Co-regulatory requirements between Medicare and the National Board
Prescribing authority and compliance with state and territory legislation
Collaborative arrangements
NMBA Guidelines for advertising of regulated health services
Notification and management of performance, conduct or health matters
52
Collaborative arrangements
› Were introduced by the Federal government to ensure midwives are able
to transfer care to a doctor when necessary
› However they are not optional, they are compulsory
› As the AMA explain "requirement for a collaborative arrangement with a
medical practitioner puts in place an overarching quality framework to
preserve patient safety and ensure that medical practitioners are not left
out of the loop"
› The legislation regarding collaborative arrangements includes:
› The National Health (Collaborative arrangements for midwives)
Determination 2010, and
› The Health Insurance Amendment Regulations 2010 (No. 1).
53
Collaborative arrangements
› Collaborative arrangements make for an interesting concept
› There is an absolute requirement for a midwife to collaborate with a doctor
but no reciprocal requirement for a doctor to collaborate with a midwife
› Thus collaboration doesn't necessarily describe the situation accurately
› It seems more like an arranged and very one-sided marriage whereby if
the midwife promises to "love, honour and obey" then the doctor promises
(we hope) to love and honour but happily agrees to be obeyed
› It seems odd that what is a completely professional expectation - namely
that a midwife would refer to or work with a doctor if (s)he believed the
patient to be high risk – becomes a matter of coercion that goes to the
heart of access to MBS
54
Add to the already complex mix the question of
homebirth
› …a valid and mainstream choice for women in many countries
› It provides many women with a satisfying and rewarding birth experience
› The right to have access to homebirth is now considered to be a fundamental
human right, according to the European Court of Human Rights in Strasbourg
(Ternovszky v. Hungary (Application no. 67545/09) 14th December 2010)
› In Australia PPMs cannot obtain PII to cover them for homebirth but all HCPs
are required to have PII in order to practise their profession.
› S.284 (discussed above in relation to the S&QF) provides an exemption for
PPMs to be able to conduct homebirths without PII providing (inter alia) there
is a S&QF in place
› However PPMs do have to have PII to cover ante and post partum care, which
means that, in order to access the government sponsored PII scheme, they
have to meet the same criteria to be notated as eligible midwives
55
How do we plan for the regulation of midwifery?
My maxims
› Good decisions are made on good information (Charlesworth M. 1989
Boyer Lectures)
› Hard cases make bad law (Rolfe J. Winterbottom v Wright 1842) –and we
have had our share of hard homebirth cases
› Thus we need evidence
› Evidence of what works here, evidence of what can work elsewhere,
evidence of what is safe
56
NMBA strategic planning
› PII - study commissioned by NMBA, completed by PwC
› SQG – revised and out for consultation
› Supervision of PPM –study commissioned by NMBA, undertaken by PwC
› Midwifery Standards for Practice – deferred due to consultation overload
› Registration standard for eligible midwives –almost completed
57
The evidence –what is safe, what works elsewhere,
what might work here
› National Institute for Clinical Excellence (UK) 2014
› Intrapartum care: care of healthy women and their babies during childbirth
› http://www.nice.org.uk/nicemedia/live/13511/67644/67644.pdf
58
Two key recommendations (p.10)
› Advise low-risk multiparous women to plan to give birth at home or in a
midwifery-led unit (freestanding or alongside). Explain that this is because
the rate of interventions is lower and the outcome for the baby is no
different compared with an obstetric unit.
› Advise low-risk nulliparous women to plan to give birth in a midwifery-led
unit (freestanding or alongside). Explain that this is because the rate of
interventions is lower and the outcome for the baby is no different
compared with an obstetric unit, but if they plan birth at home there is a
small increase in the risk of an adverse outcome for the baby.
59
The Birthplace UK study, 2011 (cohort of 65,000
women)
› There were 250 primary outcome events and an overall weighted
incidence of 4.3 per 1000 births (95% CI 3.3 to 5.5).
› Overall, there were no significant differences in the adjusted odds of the
primary outcome for any of the non-obstetric unit settings compared with
obstetric units.
› For nulliparous women, the odds of the primary outcome were higher for
planned home births (adjusted odds ratio 1.75, 95% CI 1.07 to 2.86) but
not for either midwifery unit setting.
› For multiparous women, there were no significant differences in the
incidence of the primary outcome by planned place of birth. “
60
Continuity of care midwifery models
› Caseload midwifery care versus standard maternity care for women
of any risk: M@NGO, a randomised controlled trial
› The Lancet, Volume 382, Issue 9906, Pages 1723 - 1732, 23 November
2013
Prof Sally K Tracy DMid, Donna Hartz PhD, Mark B Tracy FRACP, Jyai
Allen BMid, Amanda Forti RM, Bev Hall MIPH, Jan White RM, Anne
Lainchbury MMid, Helen Stapleton PhD, Michael Beckmann FRANZCOG,
Andrew Bisits FRANZCOG, Prof Caroline Homer PhD, Prof Maralyn
Foureur PhD, Prof Alec Welsh FRANZCOG, Prof Sue Kildea PhD
61
Findings M@NGO study
› Publicly insured women were screened at the participating hospitals
between Dec 8, 2008, and May 31, 2011.
› 1748 pregnant women were randomly assigned, 871 to caseload and
877 to standard care. The proportion of caesarean sections did not
differ between the groups (183 [21%] in the caseload group vs 204
[23%] in the standard care group;
› The proportion of women who had elective caesarean sections (before
onset of labour) differed significantly between caseload and standard
care (69 [8%] vs 94 [11%];
62
Findings (M@NGO study –cont)
› Proportions of instrumental birth were similar (172 [20%] vs 171 [19%]; as were
the proportions of unassisted vaginal births (487 [56%] vs 454 [52%]; and epidural
use (314 [36%] vs 304 [35%].
› Neonatal outcomes did not differ between the groups. T
› Total cost of care per woman was AUS$566·74 (95% 106·17—1027·30; less for
caseload midwifery than for standard maternity care.
› The results show that for women of any risk, caseload midwifery is safe and cost
effective.
63
PII Study
› The report was commissioned by NMBA to obtain information on the
uptake and provision of PII internationally, the claims and complaints
environment in relation to privately practising midwives (PPMs) providing
homebirth and the potential barriers and enablers to PII for PPMs in
Australia
› They were specifically requested to model the issues and to identify
considerations
64
PII considerations
› Specific registration of PPMs
› PPM Practice models –group practice, support, supervision
› Nationally consistent risk assessment models and frameworks for care
› Improved data collection
› Strengthened ties between industry and insurers
› Alternate insurance models
› Enhanced collaborative models to improve referral
65
The supervision project
› The scope of the project includes;
› International literature review on models of supervision for midwives &
other health professionals
› Conduct interviews & focus groups with stakeholders
› Analyse and assess models of supervision suitable for implementation in
Australia
› Recommendation of suitable & innovative models including cost and
implementation strategy
66
Where to from here?
› We believe we are proposing a robust framework for the protection of the
public for PPMs wishing to provide antepartum care in the home.
› The results of the midwifery supervision project will inform our next step.
› We hope the work we are doing and the evidence emerging about
homebirth will assist insurers to feel confident to provide PII and to obviate
the need for S.284
67
Regulation of scope of practice
› What we cannot currently do is to protect the public against unregulated
health workers who choose to assist with birth
› Some jurisdictions (such as SA) have implemented restricted birthing
practices legislation
› We would prefer a regulated scope of practice in relation to ante-natal,
intrapartum and post partum care to midwives, obstetricians and
appropriately qualified General Practitioners
› I personally would prefer it to be nationally consistent
68
In conclusion
› Professional regulation is more than registration of health professionals
› It consists of four key elements that together are designed to protect the
public from unsafe practitioners (in whatever field)
› There is a strong interface between professional education and
professional regulation
› The question of the extent to which this ought to be self regulation by the
health profession or not is vexed, particularly when a practitioner makes a
series of public and significant mistakes or behaves in a way that is
completely contrary to professional standards
› However, it is fair to say that professional regulation is a key element of
professionalism as it is one of the ways in which the public bestows its
trust and confidence in us as health professionals
› There is always work to be done 
69
The dilemma of the regulator
› “Regulation touches the point between the public and the personal. Over
regulation is seen as an interference in personal conduct; under regulation
is seen as an abdication of public responsibility. When harm happens we
blame ineffective regulation but when we are stopped from doing
something risky we say regulation is excessive. The public, media and
politicians often face both ways wanting more or less regulation depending
on the moment and the mood”.
Harry Cayton, Chief Executive, Commission for Health Care Regulatory
Excellence. Address to AHPRA Conference September 2010
Thank you -
71
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