Discussion Paper on the

"Feasibility, Assessment and Implementation Planning of the AMWAC Emergency Medicine Workforce Recommendations"

by Dr. Stephen Delprado.

(AMWAC = "Australian Medical Workforce Advisory Committee")

I am writing this paper in response to a request from the Australasian Society of Emergency Medicine (A.S.E.M.) to give the Career Medical Officers (C.M.O.) point of view, as relates to the above paper. I am the C.M.O. Association representative on the A.S.E.M., a senior C.M.O. who has worked in the South Western Area Health Service for seven years.

There are distinct problems that I see in the section titled 'Validity and Feasibility of AMWAC recommendations'. A blinkered approach has been offered in the assessment of current numbers and in projection of future numbers.

Currently working in the N.S.W. public hospital system are between 700 and 1000 C.M.O.'s, the majority of whom are based, or rotate through emergency departments. The exact number cannot be ascertained because of ambiguity in the data collection by the N.S.W. medical registration board's survey which caused many C.M.O.'s to list themselves as specialists, and many as registrars and others not to complete the survey.

These C.M.O.'s have not been considered appropriately in any of the current or future predictions. Firstly, C.M.O.'s vary. Some work in an equivalent position and with equivalent skills to specialists. Some work in equivalent positions with equivalent skills to registrars. In the statistics gathered they have all been included as registrars underestimating the current contribution for patient management.

In future predictions they again have been included as registrars with no possible allowance for increased numbers. Future numbers are unknown as the previous discussion with Federal Government on creating a C.M.O. training programme have been referred to the results of the Medical Training Review Panel (M.T.R.P.) Hospital Medical Officer (H.M.O.) subcommittee findings, which have not yet been released.

In this feasibility assessment only one alternative has been provided which is unfortunate. To truly assess feasibility one should examine alternatives and assess cost-effectiveness of alternatives:

Alternative 1.

The cost effectiveness of a C.M.O. versus a specialist in the same role.

Alternative 2.

The cost effectiveness of a combination C.M.O. and staff specialist versus purely staff specialist management system.

Alternative 3.

Different management systems for each hospital according to requirements, geographic location and casemix.

A C.M.O. is 100% clinical management and it costs, for a C.M.O.3, approximately $90,000 per annum plus penalty rates.

A specialist if 70% clinical management and with extra leave entitlements could be considered for discussion purposes the equivalent of 60% clinical management giving an effective cost of 166% of a single base salary of approximately $90,000 per annum plus penalty rates.

The difference in penalty rates between the current C.M.O. award and proposed penalty rates in the feasibility study is a ratio of 299/225.5 based on a single doctor working 168 hours per week.

Applying these values to the base rate gives a C.M.O. cost of 225.5 (total hours with penalty rates) X $90,000 = $120,803 per C.M.O. 168 (total hours in a week)

Applying these values to the base rate gives a specialist: 1.66 X 299 X $90,000 = $265,896 per Specilist 168 (total hours in a week)

I do not wish in this discussion to debase the value of a specialist emergency doctor but to reinforce the value of a C.M.O. None of the models proposed in the feasibility assessment have combination C.M.O./Specialist proposals. For example model one - 24 hour day/7 day

cover replacing 5.5 of the 15.5 FTE with C.M.O.'s could represent a net saving of 5.5 X 145,093 = $798,011. This would be relevant primarily to non-teaching hospitals. Our current C.M.O. population is primarily in non-teaching hospitals with Bankstown-Lidcombe Hospital the only N.S.W. teaching hospital with primarily C.M.O. staffing in the Emergency Department and I expect this, with time, to move to more predominant specialist staffing.

The C.M.O. and Specialist have different training bases, the specialist more academically trained and thereby sitting in a higher tier of pay, conditions and respect - and rightly so. But the C.M.O. should not be included in the lower tier of the registrar.

The staffing model I have given may not be as easily extended to other states, as primarily, it works on the N.S.W. model. C.M.O. systems vary in other states.

In Summary:

To do an analysis accurately on future staffing levels, appropriate measure should be given to each part of our current staffing levels and extrapolated into the future and appropriate action recommended ensures continuation of each level of expertise.

The above figures are used as examples only and approximates such as $90,000 base wage have been used. This base wage would vary according to seniority of C.M.O. or of staff specialist.

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Any correspondence would be welcome. I can be contacted at
The Hills Private Emergency on (02) 9686 0200 or in writing:

Dr. Stephen Delprado,
Assistant Director of Emergency,
The Hills Private Hospital,
499 Windsor Rd.,
Baulkham Hills,
N.S.W. 2153,