The following criteria is to be met to qualify an individual for appointment as a CAREER MEDICAL OFFICER:

* in the relevant area for the CMO position as determined by the relevant Credentialling Committee.

Whilst it is important that criteria are set for determining grading for CMO positions and the requirements for individuals to be appointed to CMO positions within any department, it is stressed that from time to time exceptional clinical or logistic circumstances may require some flexibilityin the application of these criteria.

The current award has no description of the various criteria to determine Grading of CMOs and CMO positions. That is provided in a subsequent Department of Health "Circular". (Circular No: 89/156)

The following criteria is to be used when determining grading for CMO positions:

* Reference: Guide to the Delineation of Roles of Area Health Services and Hospitals ISBN 07305 3216X. June, 1986.

The following criteria is to be met to qualify an individual for appointment as CMO:

It is important to remember that whilst the criteria outlined above in respect to determining grading for positions and the requirements for individuals to be appointed should be adhered to, the Corporation is cognizant that there may be instances where this is not possible. In these cases to the Human Resources Division for individual consideration and continue to refer all requests for the establishment of Career Medical Officer positions and regrading to the Human Resources Division.

The Australian Salaried Medical Officers Federation (ASMOF) advises us that both sets of existing criteria for CMO appointments and CMO positions are open to alteration and inclusion in any revised CMO award.

The CMOA Grading proposals are directed primarily at altering the latter criteria for "appointment as CMOs". The CMOA would seek advice from ASMOF & HREA about alterations to the former criteria for grading "CMO positions".

We need an Award that caters to the needs and aspirations of so-called "Middle Graded" medical officers. (ie: Doctors, who may lack formal specialist qualifications, yet choose to follow a career path providing specialised skills & expertise from hospital and community based services).

CMOs want Gradings that formally recognise their skill levels and allow "portablility" between hospitals and Area Health Services.

The Health Dept should recognise that agreeing to a Grading structure which acknowledges and rewards skill levels would foster development of expertise relevant to individual practice areas. This would lend itself to overall cost containment.

Indeed educating and employing skilled CMOs may save money. Their experience and skills may reduce attendances by specialist VMOs, minimise unnecessary investigations and unnecessary hospital admissions. Furthermore, they may identify illnesses and initiate definitive treatments at an earlier stage, thereby shortening overall hospital stays. For example employing experienced CMOs in an Accident & Emergency Department could be a hospital's first line of cost-saving measures. Providing funds for their education and training should add another "cost-saving" benefit for both the local hospital and the State Government.

It provides artificial ceilings that limit or prevent promotion, holding back experienced CMOs, worthy of progression, and stifles their moral. The current criteria even provide "Catch 22" type situations, where it implies promotion can only be gained by leaving your current CMO position.

A skills based approach can provide a career path that caters to the multi-skilled nature of CMOs' employment. It provides a focus for professional development, and removes the current ceiling on professional progression.

Many hospitals have difficult retaining experienced middle graded medical staff. With the current CMO award failing to adequately remunerate experienced staff, many hospitals are forced to step way from the award and pay higher hourly rates (approaching "locum" rates) on short-term contracts.

A Skills based award would foster staff development, providing a focus for training that could lead to longterm employment of experienced staff with significant levels of expertise.

Skills based criteria need to be developed for each area of expertise. The Multi Skilled Medical Officers (MMOs) Determination includes a set of criteria for the three levels of Accident & Emergency classification. It is suggested that these be adopted for the CMO award.

CMOs are largely employed in Accident and Emergency Departments. But they are also employed in other areas/disciplines. Notably Psychiatry, Obstetrics & Gynaecology, Alcohol & Drug Addiction, Pathology, Non-clinical areas, Developmental Disability, Prison Medical Services, Forensic Medicine, etc. Therefore "Leave should be reserved" for these CMO areas/disciplines to develop their own Skills based criteria in coming months or years, by relevant interested parties.

Skills based classifications need to be interpreted. Relevant Committees are described in the Multi- Skilled Medical Officers Agreement and it is recommended that we adopt their structures. This would include the "Credentialling Committee" and "Joint Consultative Committee".

A Means for resolving disputes is also outlined within the Multi-Skilled Medical Officers Agreement and it is recommended that this structure be modified for inclusion in the CMO award

ASMOF is currently preparing to revise or even re-invent CMO Award, offering Skills-Based Structure ready for submission to the Department of Health as early as April '99.[click here for ASMOF's presentation to the CMOA Industrial Convention , Nov 1998]

The Addition of CMO Grade 4 has been frustrated in the past. It is currently separate to these proposals. In 1992, the Department of Health's response was that it should be resolved through reform of medical workforce structures

A. Arguments to supportRemoval of the "Penalty, Overtime, Public Holiday and Call-back Payments Barrier"

There is a perception that similar barriers may exist within the NSW Award structures. They don't. The closest thing is a pure overtime barrier designed for clerical public servants. But the CMO Award doesn't stop there. It also restricts penalty loadings, holiday payments and call-backs. (Call-backs are paid at overtime rates).

No-one (including ASMOF & HREA) has been able to locate another award in NSW with a "Penalty and Public Holiday Payment Barrier".

A quick look at the table below of CMO "Base Hourly" Rates (1 July 1998) shows that the Senior Registrar rate corresponds to the rate for CMO Grade 2 Year 1.

This means CMOs beyond this level will have all Penalty, Overtime (including "Call-backs") and Public Holiday payments calculated on the Senior Registrar Rate, which can correspond to an hourly rate up to 6 levels lower than their own.

(eg: CMO Grade 3 is denied up to $8.80 per hour [Dec 1998 figures] working normal rostered hours on Sundays)

This leads to the remarkable situation where CMOs receive decreased % loadings on their ordinary hourly rate with each successive promotion. Their experience and grading may have proper financial recognition during sociable hours, but not fully financially recognised after hours, often when their presence is most greatly appreciated.

This can lead to some unique & surprising situations.          (figures calculated at Dec 1998)
For example:        

Unlike every other shift worker rostered to work on Saturdays, CMOs above Grade 2 Yr 1 do not receive 50% loading on their normal hourly rate.

Grade 3 Yr 3 CMOs receive only 38% loading, because their "50% loading" is calculated on the lower Senior Registrar rate ($36.06). This means CMO 3.3's are being denied $5.85 for every rostered hour that they work on Saturdays.

Furthermore, if the phone should ring and ask a CMO 3.3 to extend his/her shift for 2 hours overtime, then they will be accepting a further $11.70 less per hour, because they will no longer be receiving their base hourly rate. Instead they receive 150% of lower Sen Reg rate. (this corresponds to an overall loading of only 13.2% of normal hourly rate)

Even "double-time" for a CMO 3.3 is only 52% loading on his/her base hourly rate

At the CMOA Industrial Convention, Jim Deegan (Manager Industrial Services NSW AMA) pointed out that this barrier resulted from Medical Superintendents not being paid more than senior registrars when performing overtime.

Medical Superintendents typically work 9-5 during weekdays and "never" on public holidays.

Whereas full-time CMOs working in Accident and Emergency Departments are required to work all shifts, including evenings, nights and weekends, often finding that the majority of their normal rostered hours occurs during "unsociable hours" (ie:"after-hours").

If the "unsociable percentage" of ordinary hours is typically 60%, then once promoted beyond CMO Grade 2 Yr 1 (Note: there are 6 higher levels) we are being unfairly penalised MOST of the time
[ often when the presence of senior CMOs is most appreciated !]

CMOs in an Accident and Emergency Department are typically rostered to work most public holidays. Whereas most Medical Superintendents, are "never" rostered to work their ordinary hours on public holidays.

[Med Supers. were originally involved in the creation of this barrier]

Registrars maybe willing to endure minimal pay rates and conditions with the promise of career advancement or specialist qualifications.

CMOs have made their career choice and don't have the prospect of specialist salaries in the near or distant future.

CMOs are less willing to accept unreasonable conditions such as unfair limits to Penalty, Overtime, Public Holiday and Call-back Loadings.

[Still more: the final curiosity is that the award appears to remove this barrier if a CMO is "seconded" to work beyond the Area Health Service.]

Award conditions and rates of pay have fallen somewhat behind the rates and conditions achieved by colleagues on contractual arrangements. Some CMOs have even resigned their award based positions to immediately provide the same services as locums on much higher locum rates.

The current entry point (Jan '99) for an experienced CMO is only $43.56 per hr (CMO Grade 3 Yr 1). Even allowing for a 30% loading to adjust for related benefits, the consequent hourly rate ($ 56.63) still falls well short of the minimal rates some NSW hospitals are forced to pay, (through contractual arrangements) to secure the services of experienced medical staff.

For example:

One NSW Emergency Department cannot find CMOs willing to accept award conditions, despite its attractive coastal position.

Hence all its CMOs are employed on a contractual basis with hourly rates ranging from $65 to $85 per hour depending upon years of relevant experience.

These rates approaching "locum" rates, for CMOs with the necessary skills and experience.

Consequently contractual arrangements are extremely common. The award is currently an unattractive option for many.

With the current CMO award failing to adequately remunerate experienced staff, many hospitals are forced to step way from the award and pay higher hourly rates on short-term contracts.

It would seem that the overall success or failure of all these proposals depends upon both local and State Government desires to renew participation in award structures rather than allow increased participation in contractual arrangements.

1. Allowances have never been INDEXED to General salary increases.

The Qualification, In-charge, & Uniform allowances have all stood still since 1989 whilst salaries have enjoyed consiberable increases. The On-call allowances have not changed since 1992

These allowances should be corrected for salary increases over recent years

2. The On-Call allowances are generally regarded to be minimal at $10 for rostered day and $20 for rostered day off and $70 per week.

The CMOA consider that reasonable amounts for an On-call Allowance would be:

$  50 for rostered day,
$100 for rostered day off, and
$350 per week.

3. Qualification allowance made equal to "equivalent" RMO Qualification allowance.

It appears that the RMO qualification allowance may have experienced an increase that was not passed onto the CMO award. CMOs allowance appears to be currently $183 lower than RMOs equivalent alowance.

4.  In-Charge Allowance to be paid to all CMOs.

Some Area Health Services have denied this to all Grades of CMOs. It is currently the focus of a dispute between ASMOF and one Area Health Service. The Area Health Service is currently arguing that the Grading criteria for CMO 2 and 3 positions include Out of Hours Supervisory Roles.

The Allowance is described within the CMO award (regardless of CMO grading), whilst the Grading criteria are not even within the Award, but confined to a subsequent Department of Health Circular.

We will have to wait for this one to be resolved.

5. Introduction of Unpalatability Allowances.

Financial disincentives in the form of "Unpalatability Allowances" are included to acknowledge and minimise the health risks and disruption to family and social lives inherent in excessive shift work performed during unsociable hours.

With no limit to weekend or night rostering, CMOs are typically "used" to staff depts during "unsociable" hrs .. is this "planned obsolescence" for CMOs ... wait till they have children and then they'll have to leave ?

Such an allowance would follow the AMA's interest in developing the "Safe Hours" National Code of Practice.

Most shift workers find nightshift onerous

CMOs working nightshift (eg: A & E Departments) are called upon to make clinical decisions and provide optimal care without the level of medical and ancillary supports enjoyed by their daytime colleagues.

Support during nightshifts, if available, is often remote from the hospital.

CMOs report significant physical and social disruption during and following demanding periods of work at night.

For these reasons many CMOs view the current "weeknight"penalty loadings to be inadequate.

CMOs also seek the provision of hospital based sleeping quarters for CMOs exclusive use when completing nightshift or extended periods of duty and feeling unable to safely drive home.

Several CMOs have reported that they prefer to sleep immediately after nightduty. They report feeling better rested and have avoided the danger of falling asleep driving home.

"Section ii) "if more than 35 such periods on such days have been worked - leave proportionately calculated on the basis of 38 hours leave for each 35 such periods worked"

The award provides for for pro rata payments if less than 35 "such periods" are worked, but fails to provide pro-rata payments for more than 35 "such periods" worked.

Many CMOs work 50 or more such periods per year, without pro-rata payments for the last 15 or more periods.

Conditions for Maternity, Paternity and/or adoption leave are presently absent from the award, but presumed to be on some circular somewhere. The RMOs & Senior Medical Practitioners have it mentioned in their awards. The NSW Nurses have 6 pages of Provisions outlined in their award.

Perhaps now is the time to incorporate them into our award, even if only described in the form of "Parental and Adoption Leave to be provided as per ruling # ... as varied from time to time", etc

Fringe benefits tax is not applied to public hospitals. The benefits from this can be passed onto Employees. If benefits are available to senior executive staff and ASMOF is preparing arrangements for staff specialists, then why isn't it being offered to CMOs as well.

There are CMOs wishing take leave without pay to gain post-graduate qualifications without risking losing their longterm employment.

The AMA believes that prevailing medical culture needs to adjust to changing community attitudes. Employing Hospitals will become liable for adverse outcomes attributed to avoidable fatigue in employees.

CMOs should seek an entitlement to sleeping quarters for CMOs completing nightshift or extended periods of duty and feeling unable to safely drive home.

Some CMOs will no doubt lament the passing of 24 hr shifts (or longer), but we may find that we will need to embrace these changes.

such as "Preference of Employment" for those "who have been members of the Forces during the war"

The Award could do with some tidying. It has some dated attitudes and historical associations irrelevant to current medical practice.

All these adjustments have a greater chance of success if we remain relevant to the Health Care system.

We remain relevant when we deliver quality services whilst proving to be cost-effective. We need to remind and repeatedly demonstrate to the Health Dept. that experienced staff, such as CMOs, reduces overall costs.

For example in the Accident & Emegency setting, we need to demonstrate that experienced CMOs decrease the costs associated with:

- unnecessary hospital admissions

- unnecessary and A/H investigations,

- unnecessary VMO attendances.

(eg manipulation of some fractures under regional anaestheseia by CMOs rather than general anaesthesia which would require involvement of VMOs, theatre staff, and general Nursing staff, etc associated with consequent hospital admissions)

whilst possessing the necessary skills and experience to improve the overall quality and standard of medical care.

Furthermore by achieving earlier diagnosis and initiating earlier definitive treatments, experienced CMOs should help reduce morbidity and mortality, whilst reducuing the length of inpatient stays and their associated costsi

---

The world-wide trend of increasing levels of senior staff in Emergency Depts, and reducing junior staff involvement suggests that:

The First line in reducing hospital costs is:

employ experienced CMOs at the Front Door.

The Second line,

keep them there with

- adequate remuneration

- rewarding and navigable Career Structure

- adequate opportunities and funding for relevant training and education programs

---

The State Government will realise that this level of service & expertise costs money.

If we can repeatedly demonstrate that employing experienced CMOs increases the quality of care whilst reducing overall costs our future will be secure.

If we can further demonstrate that educating CMOs enhances further cost containment then we will find our training & education fully funded.

if CMOs can remain the cost-effective solution we were originally designed to be, then we can continue to provide outstanding support to the Healthcare of Australians, in busy service roles that other medical groups have traditionally been unable or unwilling to fill.

Members will have noticed an item on the AGM agenda concerning proposed changes to the rules of the Association. These are the existing rules, with proposed changes in bold italic.

1. Qualification for Membership

Rule 2

A person is qualified to be a member of the association if, and only if:

a) the person is a person referred to in section 15 (1) (a), (b) or (c) of the Act and has not ceased to be a member of the association at any time after incorporation of the association under the Act; or

(b) the person is a natural person:

(i) who has been nominated for membership of the association as provided by rule 3: and

(ii) who has been approved for membership of the association by the committee of the association.

Proposed addition to (b) as follows;

(b) the person is a natural person:

(i) who is a fully qualified medical practitioner of at least one years standing; and

(ii) who has been nominated for membership of the association as provided by rule 3: and

(iii) who has been approved for membership of the association by the committee of the association.

2 Nomination for Membership

Rule 3

(1) A nomination of a person for membership of the associaton :

(a) must be made by a member of the association in writing in the form set out in Appendix 1 of these rules: and

(b) must be lodged with the secretary of the association.

Proposed change to Rule 3 (1) as follows:

A nomination of a person for membership of the associaton :

(a) must be made by the person requesting membership of the association in writing in the modified form set out in Appendix 1 of these rules*: and

(b) must be lodged with the secretary of the association. *

[ie: Nomination form changed to delete requirement to be nominated by an existing member]

3. Fees and Subscriptions

Rule 8

(1) A member of the association must, on admission to membership, pay to the association a fee of $1 or, if some other amount is determined by the committee, that other amount.

(2) In addition to any amount payable by the member under clause (1), a member of the association must pay to the association an annual membership fee of $2 or, if some other amount is determined by the committee, that other amount

(a) except as provided by paragraph (b), before 1 July in each calandar year, or

(b) if the member becomes a member on or after 1 July in any calendar year - on becoming a member and before 1 July in each succeding calandar year.

Proposed change:

A member of the association must, on admission to membership, pay to the association an annual membership fee of $100 or, if some other amount is determined by the committee, that other amount

(a) except as provided by paragraph

(b), before 1 July in each calandar year, or

(c) if the member becomes a member on or after 1 July in any calendar year - on becoming a member and before 1 July in each succeeding calendar year.

CMOA Administration
PO Box 122
Macarthur Square
NSW 2560

email: bradford@ozemail.com.au

Karyn Bradford

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